Comparison of Military Health System Data Repository and American College of Surgeons National Surgical Quality Improvement Program-Pediatric

Comparison of the PCPLC Database to NSQIP-P: A Patient Matched Comparison of Surgical Complications Following Repair of Anorectal Malformation

BACKGROUND

Anorectal malformations (ARM) are rare and heterogenous which creates a challenge in conducting research and offering recommendations for best practice. The Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) was formed in 2016 to address this challenge and created a shared national data registry to collect information about pediatric colorectal patients. There has been no external validation of the data collected. We sought to evaluate the database by performing a patient matched analysis comparing 30-day outcomes identified in the PCPLC registry with the NSQIP-P database for patients undergoing surgical repair of ARM.

METHODS

Patients captured in the PCPLC database from 2016 to 2021 at institutions also participating in NSQIP-P who underwent ARM repair younger than 12 months old were reviewed for 30-day complications. These patients were matched to their NSQIP-P record using their hospital identification number, and records were compared for concordance in identified complications.

RESULTS

A total of 591 patient records met inclusion criteria in the PCPLC database. Of these, 180 patients were also reviewed by NSQIP-P. One hundred and fifty-six patient records had no complications recorded. Twenty-four patient records had a complication listed in one or both databases. There was a 91 % concordance rate between databases. When excluding complications not tracked in the PCPLC registry, this agreement improved to 93 %.

CONCLUSION

Including all patients evaluated for this subpopulation, a 91 % concordance rate was observed when comparing PCPLC collected complications to NSQIP-P. Future efforts can focus on further validating the data within the PCPLC for other patient populations.

LEVEL OF EVIDENCE

V.

Outcomes for Arthroplasties in Military Health: A Retrospective Analysis of Direct Versus Purchased Care

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.

Pregnancy Weight Gain and Postpartum Weight Retention in Active Duty Military Women: Implications for Readiness

INTRODUCTION

Weight gain in pregnancy is expected; however, excessive gestational weight gain and postpartum weight retention (PPWR) can cause long-term changes to a patient's body mass index (BMI) and increase the risk for adverse health outcomes. This phenomenon is understudied in active duty military women, for whom excess weight gain poses challenges to readiness and fitness to serve. This study examines over 30,000 active duty military women with and without preeclampsia to assess changes in BMI postpartum.

MATERIALS AND METHODS

This is a retrospective analysis of claims data for active duty military women, aged 18-40 years, and experiencing pregnancy during fiscal years 2010-2014. Women with eating disorders, high-risk pregnancy conditions other than preeclampsia, scheduled high-risk medical interventions, or a second pregnancy within 18 months were excluded from the analysis. Height and weight were obtained from medical records and used to calculate BMI. Women with and without preeclampsia were categorized into BMI categories according to the Centers for Disease Control and Prevention classification of underweight (BMI < 18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), or obese (>30.0). Linear regressions adjusted by age and race were performed to assess differences in prepregnancy weight and weight gain, retention, and change at 6 months postpartum.

RESULTS

The greatest number of pregnant, active duty service women were found among ages 18-24 years, White race, Army service, junior enlisted rank, married status, and with no mental health diagnosis. Overall, over 50% of women in normal and preeclamptic pregnancies returned to their baseline BMI postpartum. Women in both populations more often gained than lost weight postpartum. Preeclampsia strongly affected weight retention, with 40.77% of overweight women and 5.33% of normal weight women progressing to postpartum obesity, versus 32.95% of overweight women and 2.61% of normal weight women in the main population. Mental health conditions were not associated with significant weight gain or PPWR. Women with cesarean deliveries gained more weight during pregnancy, had more PPWR, and lost more weight from third trimester to 6 months postpartum.

CONCLUSIONS

Most women remain in their baseline BMI category postpartum, suggesting that prepregnancy weight management is an opportunity to reduce excess PPWR. Other opportunities lie in readiness-focused weight management during prenatal visits and postpartum, especially for patients with preeclampsia and cesarean sections. However, concerns about weight management for readiness must be carefully balanced against the health of the individual service members.

Ethical Considerations for Surgical Planners from the Lessons Learned on USNS COMFORT (T-AH 20) Deployment 2019

Ethical issues can arise when planning for direct patient care surgical missions. Based on the lessons learned from the USNS COMFORT Deployment 2019, the authors present concise considerations and recommendations for future hospital ship surgical mission planning.

Child Health As A National Security Issue: Obesity And Behavioral Health Conditions Among Military Children

To build and maintain an effective, agile force that is ready at a moment's notice to deploy for national security missions, the US military must recruit approximately 150,000 new personnel annually while adhering to stringent medical standards. Given a target recruitment population of young adults ages 18-24, the health of the nation's children is critical to US national security. Maintaining a fit population of military dependents is particularly important because this group has a greater propensity to serve than does the broader population of US children. Using TRICARE claims, we examined body mass index and behavioral health diagnoses among adolescents ages 13-18 covered by the Military Health System for fiscal years 2017-18. Prevalence of conduct disorders, which prevent enlistment, was low overall. However, overweight and obesity combined prevalence estimates were more than 30 percent in every census division, and the prevalence of behavioral health disorders ranged from 18.53 percent to 22.90 percent. These prevalence rates are similar to those found in the civilian sector but are high enough to pose barriers to the military's efforts to meet recruitment goals. Interventions to improve nutrition, fitness, and behavioral health among school-age children may improve fitness to serve and guarantee the future readiness of the armed forces and the security of the nation.

Epidemiology of abdominal wall and groin hernia repairs in children

PURPOSE

We sought to estimate the prevalence, incidence, and timing of surgery for elective and non-elective hernia repairs.

METHODS

We performed a retrospective cohort study, abstracting data on children < 18 years from the 2005-2014 DoD Military Health System Data Repository, which includes > 3 million dependents of U.S. Armed Services members. Our primary outcome was initial hernia repair (inguinal, umbilical, ventral, or femoral), stratified by elective versus non-elective repair and by age. We calculated prevalence, incidence rate, and time from diagnosis to repair.

RESULTS

19,398 children underwent hernia repair (12,220 inguinal, 5761 umbilical, 1373 ventral, 44 femoral). Prevalence of non-elective repairs ranged from 6% (umbilical) to 22% (ventral). Incidence rates of elective repairs ranged from 0.03 [95% CI: 0.02-0.04] (femoral) to 8.92 [95% CI: 8.76-9.09] (inguinal) per 10,000 person-years, while incidence rates of non-elective repairs ranged from 0.005 [95% CI: 0.002-0.01] (femoral) to 0.68 [95% CI: 0.64-0.73] (inguinal) per 10,000 person-years. Inguinal (median = 20, interquartile range [IQR] = 0-46 days), ventral (median = 23, IQR = 5-62 days), and femoral hernias (median = 0, IQR = 0-12 days) were repaired more promptly and with less variation than umbilical hernias (median = 66, IQR = 23-422 days).

CONCLUSIONS

These data describe the burden of hernia repair in the U.S. The large variation in time between diagnosis and repair by hernia type identifies an important area of research to understand mechanisms underlying such heterogeneity and determine the ideal timing for repair.

LEVEL OF EVIDENCE

Prognosis study II.