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Overmann AL, Harrington CJ, Richards JT, Colantonio DT, Renninger CH, Stinner DJ, Forsberg JA. What is the Case Volume of Orthopaedic Trauma Surgeons in the Military Health System? An Assessment of Wartime Readiness and Skills Sustainment. Mil Med 2024:usae314. [PMID: 38900157 DOI: 10.1093/milmed/usae314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/27/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION Complex, high-energy extremity trauma secondary to explosive mechanisms has been increasingly common in modern warfare, accounting for a majority of combat wounds throughout the conflicts in Iraq and Afghanistan. Fellowship-trained orthopaedic trauma surgeons treated many of these complex injuries; however, as the number of casualties continue to decrease during a period of relative peace, a growing concern over maintaining military trauma readiness exists. METHODS The Military Health System Data Repository was queried for all Common Procedural Terminology (CPT) codes associated with 18 fellowship-trained orthopaedic trauma surgeons from 2013 to 2019. The codes were further analyzed and categorized based on common trauma subspecialty procedures such as fracture fixation of the pelvic ring, acetabulum, upper and lower extremity, peri-articular, and nonunion/malunion surgery. We used descriptive statistics to quantify both the average number of cases per surgeon per year in each of the subcategories and case volume among Military Treatment Facilities (MTFs) during the study period. RESULTS We identified 7,769 CPT codes for surgical procedures throughout the study period. The most common surgical procedures performed were: removal of implant (n = 836, 11%), knee arthroscopy (n = 507, 7%), and debridement of devitalized tissue (n = 345, 4%). The total trauma subspecialty procedural codes and average cases per surgeon per year were as follows: pelvic ring (n = 54, <1 case/year), acetabulum (n = 90, 1 case/year), upper extremity (n = 1,314, 15 cases/year), lower extremity (n = 2,286, 25 cases/year), peri-articular (n = 675, 8 cases/year), and nonunion/malunion (n = 288, 3 cases/year). San Antonio Military Medical Center (SAMMC) accounted for the most fracture-related CPT codes overall (35%), while all other MTFs contributed approximately 10% or less of all fracture-related codes. CONCLUSIONS These results highlight the lack of orthopaedic trauma volume at other MTFs outside of SAMMC, raising concern for maintaining military readiness during an inter-war period of relative peace. The DoD continues to make concerted efforts to maintain readiness through civilian partnerships and subsequently increase surgical case volume for military trauma surgeons. Future efforts should include an in-depth analysis of caseloads of military trauma surgeons providing care at both MTFs and civilian institutions to optimize preparedness in future conflicts.
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Affiliation(s)
- Archie L Overmann
- Orthopaedic Surgery, Eisenhower Army Medical Center, Fort Eisenhower, GA 30905, USA
- Orthopaedic Surgery, Medical College of Georgia, Augusta, GA 30912, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Colin J Harrington
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - John T Richards
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Orthopaedic Surgery, Naval Medical Center LeJeune, Camp Lejeune, NC 28547, USA
| | - Donald T Colantonio
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Orthopaedic Surgery, Keller Army Community Hospital, West Point, NY 10996, USA
| | - Christopher H Renninger
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Daniel J Stinner
- Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Orthopaedic Surgery, Blanchfield Army Community Hospital, Fort Campbell, TN 42223, USA
| | - Jonathan A Forsberg
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Bozzay JD, Elster EA, Gurney JM. Sustaining Military Surgeons and the Joint Trauma System: Current Efforts, Unique Challenges, and Proposed Strategies in an Era of Global Uncertainty. ANNALS OF SURGERY OPEN 2024; 5:e395. [PMID: 38911619 PMCID: PMC11191856 DOI: 10.1097/as9.0000000000000395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/12/2024] [Indexed: 06/25/2024] Open
Abstract
Mini abstract US military assets have been integral to the response to global pandemics, natural disasters, civilian casualties, and combat care. Strategies are being implemented to strengthen the military health care system and curtail the erosion of relevant surgical skills and knowledge during periods of low combat intensity. However, additional challenges remain. We describe these strategies and obstacles but also explore potential solutions that may strengthen the readiness of military surgeons and combat trauma teams.
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Affiliation(s)
- Joseph D. Bozzay
- From the Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Eric A. Elster
- From the Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jennifer M. Gurney
- Joint Trauma System, Falls Church, VA
- Department of Surgery, Brook Army Medical Center, San Antonio, TX
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Aryankalayil J, Shields M, Baird M, Gunasingha RMKD, Pullen WM, Johnson M, Fitch J, Uber I, Worlton T. Evaluation of a Military Global Health Engagement Mission for Critical Wartime Surgical Specialty Readiness. Mil Med 2024:usae242. [PMID: 38758070 DOI: 10.1093/milmed/usae242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/29/2024] [Accepted: 04/23/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Surgical volume at Military Treatment Facilities (MTFs) has been gradually decreasing for roughly the past 2 decades. The Knowledge, Skills, and Abilities (KSA) Clinical Readiness Program linked surgical volume and readiness using a tool known as the KSA metric. However, the extent to which military medical missions contribute to the readiness of critical wartime specialties has not been evaluated using this metric. METHODS In this study, a retrospective analysis was conducted using the surgical case logs from the US Naval Ship (USNS) Comfort missions in 2018 and 2019. The comprehensive case log data were categorized by year, surgeon, procedure, and location. The analysis focused on providing detailed descriptive statistics, including percentages pertaining to the types of procedures performed during these missions. The 2018 mission was 11 weeks in duration, and supported activities in Ecuador, Peru, Colombia, and Honduras. The USNS Comfort mission in 2019 lasted 6 months (June-November 2019), and visited 12 countries in Central America, South America, and the Caribbean. RESULTS The 2019 mission case log, spanning 6 months, was evaluated using the KSA score in order to assess readiness and compare against 6 months of MTF KSA values within the same calendar year. In 2019, the orthopedic surgeon aboard the USNS Comfort had a total KSA score of 44,006, but the 6-month USNS Comfort mission only contributed 5,364 points (12% of the annual score). The general surgery practice aboard the USNS Comfort produced lower KSA scores compared to each surgeon's respective MTF practice (Table III). Analyzing the cases logged by general surgeons also highlights minimal surgical diversity during these missions, with more than 90% of cases being hernia repairs or laparoscopic cholecystectomies (Table I). In addition, 35% of total procedures performed in 2018 and 2019 were performed laparoscopically. CONCLUSIONS The analysis of operative data from the 2019 USNS Comfort mission, in comparison with the surgeons' work at their respective MTFs, reveals limited benefit in the ability of hospital-ship missions to bolster surgical readiness as measured by the KSA score. However, this is not a reflection on the value of Global Health Engagement (GHE) itself but a review of the way in which it is leveraged to support surgical readiness. Military surgeons participate in GHE as part of a larger strategy to strengthen relationships with partner nations, improve military medical force interoperability, and bolster partner nation medical capacity and capabilities. The KSA score offers an excellent tool to compare readiness metrics across significantly different GHE missions, and facilitates the opportunity for future prospective studies to improve case volume, diversity, and ultimately readiness.
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Affiliation(s)
- Joseph Aryankalayil
- General Surgery Department, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University, Bethesda, MD 20889, USA
| | - Margaret Shields
- Department of Surgery, Uniformed Services University, Bethesda, MD 20889, USA
| | - Michael Baird
- Department of Surgery, Uniformed Services University, Bethesda, MD 20889, USA
- Orthopedic Surgery Department, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | | | - W Michael Pullen
- Orthopedic Surgery Department, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Mark Johnson
- Fleet Surgical Team Four, Portsmouth, VA 23708, USA
| | - Jamie Fitch
- General Surgery Department, Naval Medical Center Camp Lejeune, Jacksonville, NC 28542, USA
| | - Ian Uber
- Eyes, Ear, Nose, and Throat Department, Naval Medicine Readiness and Training Command, Portsmouth, VA 28542, USA
| | - Tamara Worlton
- General Surgery Department, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University, Bethesda, MD 20889, USA
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Leib N, Cheney M, Burkhardt JN, Nelson E, Diffley S, Salvator A, Davis T, Robinson FE, Brown DJ, Frasier L, Sams V, Strilka RJ. Impact of Rank, Provider Specialty, and Unit Sustainment Training Frequency on Military Critical Care Air Transport Team Readiness. Mil Med 2024:usae113. [PMID: 38687580 DOI: 10.1093/milmed/usae113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/15/2024] [Accepted: 03/08/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND The Critical Care Air Transport (CCAT) Advanced Course utilizes fully immersive high-fidelity simulations to assess personnel readiness for deployment. This study aims to determine whether simple well-defined demographic identifiers can be used to predict CCAT students' performance at CCAT Advanced. MATERIALS AND METHODS CCAT Advanced student survey data and course status (pass/fail) between March 2006 and April 2020 were analyzed. The data included students' Air Force Specialty Code (AFSC), military status (active duty and reserve/guard), CCAT deployment experience (yes/no), prior CCAT Advanced training (yes/no), medical specialty, rank, and unit sustainment training frequency (never, frequency less often than monthly, and frequency at least monthly). Following descriptive analysis and comparative tests, multivariable regression was used to identify the predictors of passing the CCAT Advanced course for each provider type. RESULTS A total of 2,576 student surveys were analyzed: 694 (27%) physicians (MDs), 1,051 (40%) registered nurses (RNs), and 842 (33%) respiratory therapists (RTs). The overall passing rates were 92.2%, 90.3%, and 85.4% for the MDs, RNs, and RTs, respectively. The students were composed of 579 (22.5%) reserve/guard personnel, 636 (24.7%) with CCAT deployment experience, and 616 (23.9%) with prior CCAT Advanced training. Regression analysis identified groups with lower odds of passing; these included (1) RNs who promoted from Captain to Major (post-hoc analysis, P = .03), (2) RTs with rank Senior Airman, as compared to Master Sergeants (post-hoc analysis, P = .04), and (3) MDs with a nontraditional AFSC (P = .0004). Predictors of passing included MDs and RNs with CCAT deployment experience, odds ratio 2.97 (P = .02) and 2.65 (P = .002), respectively; and RTs who engaged in unit CCAT sustainment at least monthly (P = .02). The identifiers prior CCAT Advanced training or reserve/guard military status did not confer a passing advantage. CONCLUSION Our main result is that simple readily available metrics available to unit commanders can identify those members at risk for poor performance at CCAT Advanced readiness training; these include RNs with rank Major or above, RTs with rank Senior Airman, and RTs who engage in unit sustainment training less often than monthly. Finally, MD specialties which are nontraditional for CCAT have significantly lower CCAT Advanced passing rates, reserve/guard students did not outperform active duty students, there was no difference in the performance between different RN specialties, and for MD and RN students' previous deployment experience was a strong predictor of passing.
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Affiliation(s)
- Nicole Leib
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
| | - Mark Cheney
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Joshua N Burkhardt
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Eric Nelson
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
| | - Shannon Diffley
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
| | - Ann Salvator
- Air Force Research Laboratory Airman Biosciences Division, Wright-Patterson Air Force Base, Dayton, OH 45433, USA
| | - Tyler Davis
- United States Air Force En route Care Research Center/59th MDW/Science and Technology, JBSA-Fort Sam Houston, TX 78234, USA
| | - F Eric Robinson
- Naval Medical Research Unit Dayton, Wright-Patterson AFB, USA
| | - Daniel J Brown
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
- Department of Emergency Medicine, Wright State University, Dayton, OH 45324, USA
| | - Lane Frasier
- University of Cincinnati, Department of Surgery, Cincinnati, OH 45219, USA
| | - Valerie Sams
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
- University of Cincinnati, Department of Surgery, Cincinnati, OH 45219, USA
| | - Richard J Strilka
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
- University of Cincinnati, Department of Surgery, Cincinnati, OH 45219, USA
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Cant MR, Naumann DN, Swain C, Mountain AJ, Baden J, Bowley DM. Acquisition and retention of military surgical competencies: a survey of surgeons' experiences in the UK Defence Medical Services. BMJ Mil Health 2024; 170:117-122. [PMID: 35649691 DOI: 10.1136/bmjmilitary-2022-002112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/15/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The acquisition and retention of militarily relevant surgical knowledge and skills are vital to enable expert management of combat casualties on operations. Opportunities for skill sustainment have reduced due to the cessation of combat operations in Iraq and Afghanistan and lack of military-relevant trauma in UK civilian practice. METHODS A voluntary, anonymous online survey study was sent to all UK Defence Medical Services (DMS) surgical consultants and higher surgical trainees in Trauma and Orthopaedics, Plastic and Reconstructive, and General and Vascular surgical specialties (three largest surgical specialties in the DMS in terms of numbers). The online questionnaire tool included 20 questions using multiple choice and free text to assess respondents' subjective feelings of preparedness for deployment as surgeons for trauma patients. RESULTS There were 71 of 108 (66%) responses. Sixty-four (90%) respondents were regular armed forces, and 46 (65%) worked in a Major Trauma Centre (MTC). Thirty-three (47%) had never deployed on operations in a surgical role. Nineteen (27%) felt they had sufficient exposure to penetrating trauma. When asked 'How well do you feel your training and clinical practice prepares you for a surgical deployment?' on a scale of 1-10, trainees scored significantly lower than consultants (6 (IQR 4-7) vs 8 (IQR 7-9), respectively; p<0.001). There was no significant difference in scores between regular and reservists, or between those working at an MTC versus non-MTC. Respondents suggested high-volume trauma training and overseas trauma centre fellowships, simulation, cadaveric and live-tissue training would help their preparedness. CONCLUSIONS There was a feeling among a sample of UK DMS consultants and trainees that better preparedness is required for them to deploy confidently as a surgeon for combat casualties. The responses suggest that UK DMS surgical training requires urgent attention if current surgeons are to be ready for their role on deployed operations.
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Affiliation(s)
| | - D N Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - C Swain
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - A J Mountain
- Department of Military Trauma and Orthopaedics, Royal Centre for Defence Medicine, Birmingham, UK
| | - J Baden
- Department of Military Plastic and Reconstructive Surgery, Royal Centre for Defence Medicine, Birmingham, UK
| | - D M Bowley
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Capacio BA, McCarthy PM, West E, Oseni TO, Jones E, Coleman D, Nelson D, Bingham J, Vicente D, Choi PM. Barriers to Academic Surgery in the US Armed Forces: A Study of the AAS Military Committee. J Surg Res 2024; 293:546-552. [PMID: 37832305 DOI: 10.1016/j.jss.2023.09.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 09/10/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION The purpose of this study is to explore current perceptions within the military surgery community to stratify key obstacles to pursuing a career in academic surgery and identify opportunities for mitigation. METHODS After receiving institutional review board approval, an anonymous electronic survey was distributed to military surgeons across all branches. Survey response data were collected and analyzed using chi-square test. RESULTS The response rate was approximately 22%. Of those who responded to the survey, most are interested in an academic career (61.5%); however, 64% believe this to be much more difficult as a military surgeon than as a civilian surgeon. The top three perceived obstacles include administrative obstacles (76.4%), operational commitments (65.8%), and lack of funding for academic pursuits (62.7%). Most respondents indicated that they have never received formal education regarding how to apply for research funding (84.5%) and most do not have a research mentor (60.9%). Additionally, 42.9% state that obstacles to an academic career in surgery impact their decision to leave the military. Younger surgeons were more likely to leave the military upon completion of their service commitment (67.9% versus 46.4% aged 20-39 y, P = 0.02). CONCLUSIONS We characterized the perceived challenges to academic surgery within the military. These barriers between academic surgery and military service risk medical force attrition, particularly in future generations of surgeons. Dedicated faculty billets (positions) with limited operational demands as well as associated mentorship and research funding may enhance the retention and productivity of military surgeons.
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Affiliation(s)
- Benedict A Capacio
- Department of Surgery, Naval Medical Center San Diego, San Diego, California
| | - Patrick M McCarthy
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Erin West
- Department of Surgery, Naval Medical Center San Diego, San Diego, California
| | - Tawakalitu O Oseni
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Edward Jones
- Department of Surgery, University Of Colorado Denver, Aurora, Colorado
| | - Dawn Coleman
- Division of Vascular Surgery, Duke University, Durham, North Carolina
| | - Daniel Nelson
- Department of Surgery, William Beaumont Army Medical Center, El Paso, Texas
| | - Jason Bingham
- Department of Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Diego Vicente
- Department of Surgery, Naval Medical Center San Diego, San Diego, California
| | - Pamela M Choi
- Department of Surgery, Naval Medical Center San Diego, San Diego, California.
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Liggett JR, Norris EA, Rush TM, Sicignano NM, Oxner C. The Military Health System: Minimizing Disparities in Breast Cancer Treatment. Mil Med 2023; 188:494-502. [PMID: 37948201 DOI: 10.1093/milmed/usad218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/16/2023] [Accepted: 05/30/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND The Military Health System (MHS) is a universal health care system, in which health care disparities are theoretically minimized. This study aimed to identify disparities and assess their impact on the initiation of timely treatment for breast cancer within a universally insured population. METHODS A retrospective cohort study was performed to evaluate the treatment of female breast cancer patients ≥18 years of age within the MHS from January 1, 2014, to December 31, 2018. Incident breast cancer was defined as ≥2 breast cancer diagnoses without a prior diagnosis of breast cancer during the three continuous years before index diagnosis. Time from index diagnosis to initial treatment was calculated and dichotomized as receiving treatment within a clinically acceptable time course. Poisson regression was used to estimate relative risk (RR) with 95% CIs. RESULTS Among the 30,761 female breast cancer patients identified in the MHS, only 6% of patients had a prolonged time to initial treatment. Time to initial treatment decreased during the study period from a mean (SD) of 63.2 (152.0) days in 2014 to 37.1 (28.8) days in 2018 (P < 0.0001). Age, region, and military characteristics remained significantly associated with receiving timely treatment even after the adjustment of confounders. Patients 70-79 years old were twice as likely as 18-39 years olds to receive timely treatment (RR: 2.0100, 95% CI, 1.52-2.6563, P < 0.0001). Senior officers and their dependents were more likely to receive timely initial treatment compared to junior enlisted patients and their dependents (RR: 1.5956, 95% CI, 1.2119-2.1005, P = 0.004). CONCLUSIONS There have been significant improvements in the timely initiation of breast cancer treatment within the MHS. However, demographic and socioeconomic disparities can be identified that affect the timely initiation of therapy.
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Affiliation(s)
| | - Emily A Norris
- Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
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Haag A, Hosein S, Lyon S, Labban M, Wun J, Herzog P, Cone EB, Schoenfeld AJ, Trinh QD. Outcomes for Arthroplasties in Military Health: A Retrospective Analysis of Direct Versus Purchased Care. Mil Med 2023; 188:45-51. [PMID: 37948209 DOI: 10.1093/milmed/usac441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/21/2022] [Accepted: 01/06/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION The Department of Defense is reforming the military health system where surgeries are increasingly referred from military treatment facilities (MTFs) with direct care to higher-volume civilian hospitals under purchased care. This shift may have implications on the quality and cost of care for TRICARE beneficiaries. This study examined the impact of care source and surgical volume on perioperative outcomes and cost of total hip arthroplasties (THAs) and total knee arthroplasties (TKAs). MATERIALS AND METHODS We examined TRICARE claims for patients who underwent THA or TKA between 2006 and 2019. The 30-day readmissions, complications, and costs between direct and purchased care were evaluated using the logistic regression model for surgical outcomes and generalized linear models for cost. RESULTS We included 71,785 TKA and THA procedures. 11,013 (15.3%) were performed in direct care. They had higher odds of readmissions (odds ratio, OR 1.29 [95% CI, 1.12-1.50]; P < 0.001) but fewer complications (OR 0.83 [95% CI, 0.75-0.93]; P = 0.002). Within direct care, lower-volume facilities had more complications (OR 1.27 [95% CI, 1.01-1.61]; P = 0.05). Costs for index surgeries were significantly higher at MTFs $26,022 (95% CI, $23,393-$28,948) vs. $20,207 ($19,339-$21,113). Simulating transfer of care to very high-volume MTFs, estimated cost savings were $4,370/patient and $20,229,819 (95% CI, $17,406,971-$25,713,571) in total. CONCLUSIONS This study found that MTFs are associated with lower odds of complications, higher odds of readmission, and higher costs for THA and TKA compared to purchased care facilities. These findings mean that care in the direct setting is adequate and consolidating care at higher-volume MTFs may reduce health care costs.
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Affiliation(s)
- Austin Haag
- Hankamer School of Business, Baylor University, Waco, TX 76706, USA
| | - Sharif Hosein
- SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Samuel Lyon
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Muhieddine Labban
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02115, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jolene Wun
- Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Peter Herzog
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02115, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Eugene B Cone
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02115, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Quoc-Dien Trinh
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02115, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Dewar C, Ravindra VM, Woodle S, Scanlon M, Shields M, Yokoi H, Meister M, Porensky P, Bossert S, Ikeda DS. Effect of Fusion and Arthroplasty for Cervical Degenerative Disc Disease in Active Duty Service Members Performed at an Overseas Military Treatment Facility: A 2-Year Retrospective Analysis. Mil Med 2023; 188:e3454-e3462. [PMID: 37489817 DOI: 10.1093/milmed/usad280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/13/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023] Open
Abstract
INTRODUCTION Among U.S. military active duty service members, cervicalgia, cervical radiculopathy, and myelopathy are common causes of disability, effecting job performance and readiness, often leading to medical separation from the military. Among surgical therapies, anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are options in select cases; however, elective surgeries performed while serving overseas (OCONUS) have not been studied. MATERIALS AND METHODS A retrospective analysis of a prospectively collected surgical database from an OCONUS military treatment facility over a 2-year period (2019-2021) was queried. Patient and procedural data were collected to include ACDF or CDA surgery, military rank, age, tobacco use, pre- and post-operative visual analogue scales for pain, and presence of radiographic fusion after surgery for ACDF patients or heterotopic ossification for CDA patients. Chi-square and Student t-test analyses were performed to identify variables associated with return to full duty. RESULTS A total of 47 patients (25 ACDF and 22 CDA) underwent surgery with an average follow-up of 192.1 days (range 7-819 days). Forty-one (87.2%) patients were able to return to duty without restrictions; 10.6% of patients remained on partial or limited duty at latest follow-up and one patient was medically separated from the surgical cohort. There was one complication and one patient required tour curtailment from overseas duty for ongoing symptoms. CONCLUSIONS Both ACDF and CDA are effective and safe surgical procedures for active duty patients with cervicalgia, cervical radiculopathy, and cervical myelopathy. They can be performed OCONUS with minimal interruption to the patient, their family, and the military unit, while helping to maintain surgical readiness for the surgeon and the military treatment facility.
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Affiliation(s)
- Callum Dewar
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Samuel Woodle
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Michaela Scanlon
- Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA
| | - Margaret Shields
- Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA
| | - Hana Yokoi
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Melissa Meister
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Paul Porensky
- Department of Neurosurgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Sharon Bossert
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Daniel S Ikeda
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
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Hall AB, Krzyzaniak M, Qureshi I, Cromer R, Tadlock MD, Patrick D, Hatch Q, Iverson MK, Walker A, Glaser J. Declining Military Surgical Cases and the Impact on Military Surgical Graduate Medical Education. Am Surg 2023; 89:4316-4320. [PMID: 35722906 DOI: 10.1177/00031348221109451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Several studies have indicated a decline in the number, types, and complexity of surgical procedures within military treatment facilities (MTFs). This study aims to determine what effect, if any, these downward trends have had on the relationship between the military health system (MHS) and surgical graduate medical education. METHODS Graduating chief resident final ACGME case logs from 4 of thirteen military general surgery programs were evaluated from 2015 to 2020. The proportion of total cases performed by residents at military institutions were compared on a year over year basis. RESULTS The proportion of cases performed within the military hospitals declined 3.27% each year between 2015 and 2020 (P < .0001) in 4 MTFs. All individual hospitals had significant declines in case volume except one (William Beaumont Army Medical Center) which increased 6.05% with each year, but also increased the number of MTF partnerships within its program (P < .0001). CONCLUSIONS There has been a statistically significant decline over time in the proportion of cases logged by residents within the studied military treatment facilities. Investment into military hospitals to increase case numbers, case diversity, and complexity and/or acceptance of this gradual decline with greater shifting of educational workload onto civilian hospitals is required.
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Affiliation(s)
| | | | - Iram Qureshi
- Naval Medical Research Unit San Antonio, San Antonio, TX, USA
| | - Robert Cromer
- Department of Surgery, Keesler Medical Center, MS, USA
| | | | | | - Quinton Hatch
- Department of Surgery, Madigan Army Medical Center, WA, USA
| | | | - Avery Walker
- William Beaumont Army Medical Center, Fort Bliss, TX, USA
| | - Jacob Glaser
- Naval Medical Research Unit San Antonio, San Antonio, TX, USA
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11
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Suydam CR, Aranda MC, O'Hara TA, Kobylarz FC, Liang JN, Bandera B. Practice patterns of hepatobiliary surgery within the military. Surg Endosc 2023; 37:7502-7510. [PMID: 37415016 PMCID: PMC10520085 DOI: 10.1007/s00464-023-10150-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND The purpose of this study is to evaluate the trends of hepatobiliary surgeries performed at military hospitals and to discuss potential implications on resident training and military readiness. While there is data to suggest centralization of surgical specialty services leads to improved patient outcomes, the military does not currently have a specific centralization policy. Implementation of such a policy could potentially impact resident training and readiness of military surgeons. Even in the absence of such a policy, there may still be a trend toward centralization of more complex surgeries like hepatobiliary surgeries. The present study evaluates the numbers and types of hepatobiliary procedures performed at military hospitals. METHODS This study is a retrospective review of de-identified data from Military Health System Mart (M2) from 2014 to 2020. The M2 database contains patient data from all Defense Health Agency treatment facilities, encompassing all branches of the United States Military. Variables collected include number and types of hepatobiliary procedures performed and patient demographics. The primary endpoint was the number and type of surgery for each medical facility. Linear regression was used to evaluate significant trends in numbers of surgeries over time. RESULTS Fifty-five military hospitals performed hepatobiliary surgeries from 2014 to 2020. A total of 1,087 hepatobiliary surgeries were performed during this time; cholecystectomies, percutaneous procedures, and endoscopic procedures were excluded. There was no significant decrease in overall case volume. The most commonly performed hepatobiliary surgery was "unlisted laparoscopic liver procedure." The military training facility with the most hepatobiliary cases was Brooke Army Medical Center. CONCLUSION The number of hepatobiliary surgeries performed in military hospitals has not significantly decreased over the years 2014-2020, despite a national trend toward centralization. Centralization of hepatobiliary surgeries in the future may impact residency training as well as military medical readiness.
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Affiliation(s)
- Camille R Suydam
- Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, USA.
| | - Marcos C Aranda
- Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, USA
| | - Thomas A O'Hara
- Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, USA
| | - Fred C Kobylarz
- Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, USA
| | - Joy N Liang
- Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, USA
| | - Bradley Bandera
- Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, USA
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12
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Sheldon RR, Bozzay JD, Brown SR. Case Volume and Readiness to Deploy: Clinical Opportunities for Active-Duty Surgeons Outside of Military Hospitals. J Am Coll Surg 2023; 237:221-228. [PMID: 36999735 DOI: 10.1097/xcs.0000000000000697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
BACKGROUND The Military Health System (MHS) uses a readiness program that identifies the knowledge, skills, and abilities (KSAs) necessary for surgeons to provide combat casualty care. Operative productivity is assigned an objective score based on case type and complexity and totaled to assess overall readiness. As of 2019, only 10.1% of surgeons met goal readiness threshold. At one tertiary military treatment facility (MTF), leadership has taken an aggressive approach toward increasing readiness by forming military training agreements (MTAs) and allowing Off Duty Employment (ODE). We sought to quantify the efficacy of this approach. STUDY DESIGN Operative logs from 2021 were obtained from surgeons assigned to the MTF. Operations were assigned CPT codes and processed through the KSA calculator (Deloitte; London, UK). Each surgeon was then surveyed to identify time away from clinical duties for deployment or military training. RESULTS Nine surgeons were present in 2021 and spent an average of 10.1 weeks (19.5%) abroad. Surgeons performed 2,348 operations (Average [Avg] 261 ± 95) including 1,575 (Avg 175; 67.1%) at the MTF, 606 (Avg 67.3; 25.8%) at MTAs, and 167 (Avg 18.6, 7.1%) during ODE. Adding MTA and ODE caseloads increased KSA scores by 56% (17,765 ± 7,889 vs 11,391 ± 8,355). Using the MHS threshold of 14,000, 3 of 9 (33.3%) surgeons met the readiness threshold from MTF productivity alone. Including all operations, 7 of 9 (77.8%) surgeons met threshold. CONCLUSIONS Increased use of MTAs and ODE significantly augments average caseloads. These operations provide considerable benefit and result in surgeon readiness far exceeding the MHS average. Military leadership can maximize the chances of meeting readiness goals by encouraging clinical opportunities outside the MTF.
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Affiliation(s)
- Rowan R Sheldon
- From the Department of Surgery, Womack Army Medical Center, Fort Bragg, NC (Sheldon, Bozzay, Brown)
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD (Sheldon, Bozzay, Brown)
| | - Joseph D Bozzay
- From the Department of Surgery, Womack Army Medical Center, Fort Bragg, NC (Sheldon, Bozzay, Brown)
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD (Sheldon, Bozzay, Brown)
| | - Shaun R Brown
- From the Department of Surgery, Womack Army Medical Center, Fort Bragg, NC (Sheldon, Bozzay, Brown)
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD (Sheldon, Bozzay, Brown)
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13
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Worlton TJ, Gunasingha RMKD, Atwood R, Johnson M, Uber IC. A Decade of Surgery Aboard the U.S. Naval Ship COMFORT (T-AH 20). Mil Med 2023; 188:e1802-e1807. [PMID: 36242546 DOI: 10.1093/milmed/usac278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/29/2022] [Accepted: 09/11/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The U.S. Naval Ship COMFORT has performed six humanitarian assistance and disaster relief mission since 2007. This paper describes the surgical volume per surgical specialty for five missions spanning 19 countries. MATERIALS AND METHODS Raw surgical case logs were analyzed for total case volume, total operating days, unanticipated return to operating room, and percentage of pediatric cases (<18 years old) for each country visited. RESULTS Total surgical volume for the five missions was 5,142. The countries most frequently visited were Columbia and Haiti with seven and five visits, respectively. General surgery, ophthalmology, and plastic surgery have had consistent volume over time. Orthopedic surgery volume has steadily decreased with the exception of the 2018 mission. CONCLUSION As volume in military treatment facilities declines, alternative sources of surgical volume for military surgeons are being examined. This paper highlights the historical volume which can inform future personnel planning requirements of U.S. Naval Ship COMFORT missions. With the exception of orthopedic surgery, surgical volume has remained consistent over the last decade. For future best practice, historical case data should be used to determine staffing needs on hospital ships and case logs and operating procedures and follow-up protocols should be standardized.
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Affiliation(s)
- Tamara J Worlton
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | | | - Rex Atwood
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Mark Johnson
- Department of General Surgery, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA
| | - Ian C Uber
- Department of Ophthalmology, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA
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Vasquez M, Edson TD, Lucas DJ, Hall AB, Tadlock MD. The Impact of the Maritime Deployment Cycle on the Surgeon's Knowledge, Skills, and Abilities. Mil Med 2023; 188:e1382-e1388. [PMID: 36260423 DOI: 10.1093/milmed/usac316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/30/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The U.S. Navy routinely deploys aircraft carriers and amphibious assault ships throughout the world in support of U.S. strategic interests, each with an embarked single surgeon team. Surgeons and their teams are required to participate in lengthy pre-deployment shipboard certifications before each deployment. Given the well-established relationship of surgeon volume to patient outcome, we aim to compare the impact of land vs. maritime deployments on Navy general surgeon practice patterns. MATERIALS AND METHODS Case logs and pre-deployment training initiation of land-based (n = 8) vs. maritime-based (n = 7) U.S. Navy general surgeons over a 3-year period (2017-2020) were compared. Average cases per week were plotted over 26 weeks before deployment. Student's t-test was utilized for all comparisons. RESULTS Cases declined for both groups in the weeks before deployment. At 6 months (26 weeks) before deployment, land-based surgeons performed significantly more cases than their maritime colleagues (50.3 vs. 14.0, P = .009). This difference persisted at 16 weeks (13.1 vs. 1.9, P = .011) and 12 weeks (13.1 vs. 1.9, P = .011). Overall, surgeon operative volume fell off earlier for maritime surgeons (16 weeks) than land-based surgeons (8 weeks). Within 8 weeks of deployment, both groups performed a similarly low number of cases as they completed final deployment preparations. CONCLUSIONS Surgeons are a critical component of combat causality care teams. In this analysis, we have demonstrated that both land- and maritime-based U.S. Navy surgeons have prolonged periods away from clinical care before and during deployments; for shipboard surgeons, this deficit is large and may negatively impact patient outcomes in the deployed maritime environment. The authors describe this discrepancy and provide practical doctrinal solutions to close this readiness gap.
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Affiliation(s)
- Matthew Vasquez
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92058, USA
- Department of Surgery, Navy Medicine Readiness and Training Command, San Diego, CA 92134, USA
| | - Theodore D Edson
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92058, USA
| | - Donald J Lucas
- Department of Surgery, Navy Medicine Readiness and Training Command, San Diego, CA 92134, USA
| | - Andrew B Hall
- Department of Surgery, Navy Medicine Readiness and Training Command, CENTCOM, CA 33621, USA
| | - Matthew D Tadlock
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92058, USA
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15
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Woodle S, Ravindra VM, Dewar C, Yokoi H, Meister M, Curry B, Miller C, Ikeda DS. Craniotomies at an overseas military treatment facility: Maintaining readiness for the unit and the surgeon. Clin Neurol Neurosurg 2023; 230:107742. [PMID: 37178524 DOI: 10.1016/j.clineuro.2023.107742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Craniotomy and craniectomy are common neurosurgical procedures with wide applications in both civilian and military practice. Skill maintenance for these procedures is required for military providers in the event they are called to support forward deployed service members suffering from combat and non-combat injuries. The presents investigation details the performance of such procedures at a small, overseas military treatment facility (MTF). MATERIALS AND METHODS A retrospective review of craniotomy procedures performed at an overseas military treatment facility (MTF) over a 2-year period (2019-2021) was performed. Patient and procedural data were collected for all elective and emergent craniotomies including surgical indications, outcomes, complications, military rank, and impact on duty status and tour curtailment. RESULTS A total of 11 patients underwent a craniotomy or craniectomy procedure with an average follow-up of 496.8 days (range 103-797). Seven of the 11 patients were able to undergo surgery, recovery, and convalesce without transfer to a larger hospital network or MTF. Of the 6 patients that were active duty (AD), one returned to full duty while three separated and two remain in partial duty status at latest follow-up. There were four complications in four patients with one death. CONCLUSIONS In this series, we demonstrate that cranial neurosurgical procedures can be performed safely and effectively while at an overseas MTF. There are potential benefits to the AD service members, their unit, and family as well as to the hospital treatment team and surgeon as this represents a clinical capability requisite to maintain trauma readiness for future conflicts.
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Affiliation(s)
- Samuel Woodle
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Callum Dewar
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Hana Yokoi
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Melissa Meister
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Brian Curry
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Charles Miller
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Daniel S Ikeda
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA.
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16
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Dougherty PJ. CORR® Curriculum-Orthopaedic Education: Whither the Military Residency? Clin Orthop Relat Res 2023; 481:1075-1077. [PMID: 37098212 PMCID: PMC10194737 DOI: 10.1097/corr.0000000000002676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/31/2023] [Indexed: 04/27/2023]
Affiliation(s)
- Paul J Dougherty
- Professor and Chairman, Department of Orthopaedic Surgery, University of Florida, Jacksonville, FL, USA
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17
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Carnduff M, Place R. Authors' Response to Letter to the Editor Regarding "The Relation of Surgical Volume to Competence: When is Enough, Enough?". Mil Med 2023; 188:88-89. [PMID: 36367119 DOI: 10.1093/milmed/usac337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/16/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mary Carnduff
- Office of the Under Secretary of the Air Force, Washington, DC 20310, USA
| | - Ronald Place
- Defense Health Agency, Falls Church, VA 22042, USA
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18
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Osborn PM. Letter to the Editor Regarding "The Relation of Surgical Volume to Competence: When Is Enough, Enough?". Mil Med 2023; 188:85-87. [PMID: 36369965 DOI: 10.1093/milmed/usac336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/15/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Patrick M Osborn
- Northeast Orthopaedics and Sports Medicine, San Antonio, TX 78217, USA
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19
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Williams J, Francis A, Prey B, Conner J, Lammers D, Choi PM, Vicente D, Bingham J, McClellan J. Impact of COVID on surgical case volume at military treatment facilities with surgical residencies. Am J Surg 2023; 225:897-902. [PMID: 36764898 DOI: 10.1016/j.amjsurg.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/21/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The Military Health System (MHS) is tasked with the dual mission of providing medical care to beneficiaries while ensuring medical readiness. MHS provides care through a combination of military treatment facilities (MTF) ("direct care"; DC) & off-base civilian facilities ("purchased care"; PC). Given recent concerns regarding low surgical volume at MTFs, we sought to evaluate COVID's impact on elective and non-elective case volume at MTFs with surgical residencies. METHODS Retrospective review of 2017-2021 M2 database was performed on Tricare beneficiaries who underwent bariatric surgery or major colorectal surgery in the DC or PC market at, or, surrounding MTFs with surgical residencies. Procedures were identified using ICD-10 procedure codes and Medicare severity-diagnosis related groups. A detailed analysis was then performed on changes in case volume in the DC and PC markets. RESULTS 5,698 bariatric and 5,517 major colorectal procedures were performed during the study period. There was an 84% vs 20% quarterly decrease in elective bariatric surgeries completed in the DC and PC markets from Q1 to Q2 2020. Pre to post-COVID (Q1 2017 - Q1 2020 vs Q3 2020 - Q4 2021) there was a decrease in the percentage of bariatric surgeries completed in the DC market (74.1% vs 55.0%, p = 0.001). Meanwhile, major colorectal surgery quarterly case volume remained unchanged in the DC (137 vs 125, p = 0.18) and PC (146 v 137, p = 0.13) markets, pre- and post-COVID. DISCUSSION Bariatric surgical case volume at MTFs disproportionately decreased during COVID when compared to the PC market and major colorectal cases. Bariatric case volume has rebounded in PC markets surpassing pre-COVID levels while DC case volume remains depressed. Further attention is warranted regarding decreased elective surgical case volume at MTFs.
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Affiliation(s)
| | | | - Beau Prey
- Madigan Army Medical Center, Tacoma, WA, USA
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20
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Osborn PM, Tansey KA. Ascertaining the Readiness of Military Orthopedic Surgeons: A Revision to the Knowledge, Skills, and Abilities Methodology. Mil Med 2022; 188:usac135. [PMID: 35596550 DOI: 10.1093/milmed/usac135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/18/2022] [Accepted: 05/01/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Decay of military surgeons' critical wartime skills is a persistent and growing concern among leaders in the military health system (MHS). The Knowledge, Skills and Abilities (KSA) Clinical Readiness Program was developed to quantify the readiness of clinicians in the MHS; however, the utility of the data is questionable due to a lack of focus on the operative expeditionary skillset in the original methodology. A revised methodology emphasizing the most relevant to expeditionary orthopedic surgery procedures is described. MATERIALS AND METHODS All Current Procedural Terminology (CPT) codes included in the original KSA methodology were reviewed and, if appropriate, removed, or reassigned to more suitable categories. Category scores were weighted to better align with the most performed procedures in the deployed environment. All surgical cases and procedures performed from 2017-2019 in military treatment facilities by orthopedic surgeons were recorded in total and by MHS market. Cases were recorded for all military orthopedic surgeons who performed at least one KSA credit procedure during the study period. The 10 MHS markets with the greatest number of procedures were included in the analysis. The change in creditable KSA procedure codes and procedures performed from the original to revised methodology was determined for each KSA category and MHS market. RESULTS Overall, 403 CPT codes were recategorized and 79 were deleted from the original KSA methodology. The deletions represented less than 4% of the original creditable CPT codes, with most being supply or injection codes. Three of the five most common expeditionary KSA categories increased in the number of creditable procedure codes. The impact of the revision on the MHS markets was mixed, but the overall volume of credited procedures decreased. The weighted scoring did not disproportionately affect the analyzed markets. CONCLUSIONS The revised methodology is better aligned with the most common procedures in the most recent large-scale military engagements. The improved applicability of the KSA scoring to necessary CWS will allow military medical leaders to better determine the readiness opportunities available in the MHS.
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Affiliation(s)
- Patrick M Osborn
- Department of Orthopedic Surgery, Brooke Army Medical Center, Fort Sam Houston TX 78234, USA
| | - Kimberly A Tansey
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston TX 78234, USA
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21
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Lee JJ, Hall AB, Carr MJ, MacDonald AG, Edson TD, Tadlock MD. Integrated military and civilian partnerships are necessary for effective trauma-related training and skills sustainment during the inter-war period. J Trauma Acute Care Surg 2022; 92:e57-e76. [PMID: 34797811 DOI: 10.1097/ta.0000000000003477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Joseph J Lee
- From the Department of Surgery (J.J.L., M.J.C., M.D.T.), Navy Medicine Readiness & Training Command, San Diego, California; 96th Medical Group (A.B.H.), US Air Force Regional Hospital, Eglin AFB, Florida; Uniformed Services University of the Health Sciences (A.G.M.), Bethesda, Maryland; and 1st Medical Battalion (T.D.E.), 1st Marine Logistics Group, Camp Pendleton, California
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22
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Rask DMG, Tansey KA, Osborn PM. Impact of Civilian Patient Care on Major Amputation Case Volume in the Military Health System. Mil Med 2022; 188:usab534. [PMID: 34986247 DOI: 10.1093/milmed/usab534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/07/2021] [Accepted: 12/14/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Sustaining critical wartime skills (CWS) during interwar periods is a recurrent and ongoing challenge for military surgeons. Amputation surgery for major extremity trauma is exceptionally common in wartime, so maintenance of surgical skills is necessary. This study was designed to examine the volume and distribution of amputation surgery performed in the military health system (MHS). STUDY DESIGN All major amputations performed in military treatment facilities (MTF) for calendar years 2017-2019 were identified by current procedural terminology (CPT) codes. The date of surgery, operating surgeon National Provider Identifier, CPT code(s), amputation etiology (traumatic versus nontraumatic), and beneficiary status (military or civilian) were recorded for each surgical case. RESULTS One thousand one hundred and eighty-four major amputations at 16 of the 49 military's inpatient facilities were identified, with two MTFs accounting for 46% (548/1,184) of the total. Six MTFs performed 120 major amputations for the treatment of acute traumatic injuries. Seventy-three percent (87/120) of traumatic amputations were performed at MTF1, with the majority of patients (86%; 75/87) being civilians emergently transported there after injury. Orthopedic and vascular surgeons performed 78% of major amputations, but only 9.7% (152/1,570) of all military surgeons performed any major amputation, with only 3% (52) involved in amputations for trauma. Nearly all (87%; 26/30) of the orthopedic surgeons at MTF1 performed major amputations, including those for trauma. CONCLUSION This study highlights the importance of civilian patient care to increase major amputation surgical case volume and complexity to sustain critical wartime skills. The preservation and strategic expansion of effective military-civilian partnerships is essential for sustaining the knowledge and skills for optimal combat casualty care.
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Affiliation(s)
- Dawn M G Rask
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- Department of Orthopaedic Surgery, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX 78234, USA
| | - Kimberly A Tansey
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Patrick M Osborn
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- Department of Orthopaedic Surgery, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX 78234, USA
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23
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Dalton MK, Remick KN, Mathias M, Trinh QD, Cooper Z, Elster EA, Weissman JS. Analysis of Surgical Volume in Military Medical Treatment Facilities and Clinical Combat Readiness of US Military Surgeons. JAMA Surg 2021; 157:43-50. [PMID: 34705038 DOI: 10.1001/jamasurg.2021.5331] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Low surgical volume in the US Military Health System (MHS) has been identified as a challenge to military surgeon readiness. The Uniformed Services University of Health Sciences, in partnership with the American College of Surgeons, developed the Knowledge, Skills, and Abilities (KSA) Clinical Readiness Program that includes a tool for quantifying the clinical readiness value of surgeon workload, known as the KSA metric. Objective To describe changes in US military general surgeon procedural volume and readiness using the KSA metric. Design, Setting, and Participants This cohort study analyzed general surgery workload performed across the MHS, including military and civilian facilities, between fiscal year 2015 and 2019 and the calculated KSA metric value. The surgeon-level readiness among military general surgeons was calculated based on the KSA metric readiness threshold. Data were obtained from TRICARE, the US Department of Defense health insurance product. Main Outcomes and Measures The main outcomes were general surgery procedural volumes and the KSA metric point value of those procedures across the MHS as well as the number of military general surgeons meeting the KSA metric readiness threshold. Aggregate facility and regional market-level claims data were used to calculate the procedural volumes and KSA metric readiness value of those procedures. Annual adjusted KSA metric points earned were used to determine the number of individual US military general surgeons meeting the readiness threshold. Results The number of general surgery procedures generating KSAs in military hospitals decreased 25.6%, from 128 377 in 2015 to 95 461 in 2019, with a 19.1% decrease in the number of general surgeon KSA points (from 7 155 563 to 5 790 001). From 2015 to 2019, there was a 3.2% increase in both the number of procedures (from 419 980 to 433 495) and KSA points (from 21 071 033 to 21 748 984) in civilian care settings. The proportion of military general surgeons meeting the KSA metric readiness threshold decreased from 16.7% (n = 97) in 2015 to 10.1% (n = 68) in 2019. Conclusions and Relevance This study noted that the number of KSA metric points and procedural volume in military hospitals has been decreasing since 2015, whereas both measures have increased in civilian facilities. The findings suggest that loss of surgical workload has resulted in further decreases in military surgeon readiness and may require substantial changes in patient care flow in the MHS to reverse the change.
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Affiliation(s)
- Michael K Dalton
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Kyle N Remick
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Quoc-Dien Trinh
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Joel S Weissman
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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24
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Bowyer MW, Andreatta PB, Armstrong JH, Remick KN, Elster EA. A Novel Paradigm for Surgical Skills Training and Assessment of Competency. JAMA Surg 2021; 156:1103-1109. [PMID: 34524418 DOI: 10.1001/jamasurg.2021.4412] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Sustainment of comprehensive procedural skills in trauma surgery is a particular problem for surgeons in rural, global, and combat settings. Trauma care often requires open surgical procedures for low-frequency/high-risk injuries at a time when open surgical experience is declining in general and trauma surgery training. Objective To determine whether general surgeons participating in a 2-day standardized trauma skills course demonstrate measurable improvement in accuracy and independent performance of specific trauma skills. Design, Setting, and Participants General surgeons in active surgical practice were enrolled from a simulation center with anatomic laboratory from October 2019 to October 2020. Differences in pretraining/training and posttraining performance outcomes were examined using (1) pretraining/posttraining surveys, (2) pretraining/posttraining knowledge assessment, and (3) training/posttraining faculty assessment. Analysis took place in November 2020. Interventions A 2-day standardized, immersive, cadaver-based skills course, developed with best practices in instructional design, that teaches and assesses 24 trauma surgical procedures was used. Main Outcomes and Measures Trauma surgery capability, as measured by confidence, knowledge, abilities, and independent performance of specific trauma surgical procedures; 3-month posttraining skill transfer. Results The study cohort included 65 active-duty general surgeons, of which 16 (25%) were women and 49 (75%) were men. The mean (SD) age was 38.5 (4.2) years. Before and during training, 1 of 65 participants (1%) were able to accurately perform all 24 procedures without guidance. After course training, 64 participants (99%) met the benchmark performance requirements for the 24 trauma procedures, and 51 (78%) were able to perform them without guidance. Procedural confidence and knowledge increased significantly from before to after the course. At 3 months after training, 37 participants (56%) reported skill transfer to trauma or other procedures. Conclusions and Relevance In this study, direct measurement of procedural performance following standardized training demonstrated significant improvement in skill performance in a broad array of trauma procedures. This model may be useful for assessment of procedural competence in other specialties.
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Affiliation(s)
- Mark W Bowyer
- Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Pamela B Andreatta
- Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - John H Armstrong
- Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland.,University of South Florida Morsani College of Medicine, Tampa
| | - Kyle N Remick
- Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland
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25
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Carnduff M, Place R. The Relation of Surgical Volume to Competence: When Is Enough, Enough? Mil Med 2021; 187:64-67. [PMID: 34453173 DOI: 10.1093/milmed/usab356] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/20/2021] [Accepted: 08/16/2021] [Indexed: 11/12/2022] Open
Abstract
Given the inherent risk in surgical intervention and the need for the optimal utilization of health care resources, achieving high-quality surgical care is a priority for the American health care system, and competent surgeons are critical to reaching this goal. Despite the multifactorial nature of patient safety and satisfaction, surgeon competence is often oversimplified to an assessment of volume because of the ease of collection and comparison. In any practice model, the analysis of competence is complex, but the components of clinical skill for military surgeons further include multiple areas of expertise, which, although superficially unrelated to surgical currency, augment the overall care delivered by these clinicians. Thus, volume as a solitary indicator of skill excludes the unique circumstances encompassed in military service. In this paper, the factors comprising volume and competence are explained, as well as the additional factors unique to military medicine. Furthermore, process improvements are proposed for assessing and optimizing surgical competence in the Military Health System.
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Affiliation(s)
| | - Ronald Place
- Defense Health Agency, Falls Church, VA 22042, USA
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