Implementation interventions for musculoskeletal programs of care in the active military and barriers, facilitators, and outcomes of implementation: a scoping review

Quantitative Analysis of Condition-based Limited Duty Duration of Musculoskeletal Conditions

INTRODUCTION

Musculoskeletal injuries affect nearly a million service members annually within the DoD, ultimately costing the U.S. Military half a billion dollars in direct patient costs and a significant loss to fleet readiness as many members are assigned days on limited duty (LIMDU) until they are deemed medically fit to return to duty (RTD). The new approach implemented by Navy Medicine in 2022, called "condition-based LIMDU," aims to drastically impact the time in which Sailors and Marines spend under a provider's care by assigning LIMDU days based on a standardized set of guidelines. This study provides a quantitative analysis on LIMDU duration, before and after implementation of the new condition-based LIMDU paradigm, to increase the understanding on the effectiveness and impact to fleet readiness and to assess the accuracy of suggested patient outcome timelines.

MATERIALS AND METHODS

De-identified and aggregated data were obtained from the Naval Medical Forces Atlantic's (NMFL) LIMDU Sailor and Marine Readiness Tracker System (SMART) program for all active duty military patients with ICD-10 code for musculoskeletal conditions. Only closed LIMDU cases in which active duty patients were given a final status of RTD were included. This study analyzed top musculoskeletal ICD-10 codes, optimum period (weeks), maximum period (weeks), and average days on LIMDU assigned at NMFL centers (medical and non-medical) for fiscal years 2021 (FY21) and 2022 (FY22). As well as descriptive statistics, t-test analysis was used to test if there was a difference between FY21 and FY22 and at what point the difference was no longer significant. Critical value method was then used to compare the top five most common musculoskeletal injuries to determine the accuracy of recommended LIMDU days to actual average assigned LIMDU per injury type. A color-coded compliance chart was created based on the results.

RESULTS

The results showed that for RTD population, the implementation of condition-based LIMDU significantly decreased average days assigned on LIMDU by 33%. In fact, there is a 35-day (5-week) difference before we can confidently say that the difference between FY21 and FY22 is no longer statistically significant. This significant decrease in LIMDU days, before and after implementation, is a trend consistent at both medical and non-medical NMFL centers; however, medical centers reported significantly more assigned LIMDU days for both years. The five most common injuries of FY21 and FY22 were low back pain, pain in shoulder, pain in hip, pain in knee, and pain in ankle. Before implementation, all five of these injury types far exceeded the recommended amount of LIMDU days. With the new condition-based LIMDU paradigm, the average assigned LIMDU days for pain in hip, pain in knee, and pain in ankle were all found to be in compliance with the recommended LIMDU days within a 99% confidence level.

CONCLUSIONS

The new condition-based LIMDU paradigm is successful in its aim to improve fleet readiness by returning Sailors and Marines to full duty status significantly faster. Regular assessment of ICD-10 diagnosis codes and update to recommended LIMDU assignment timelines should be conducted to maximize the effectiveness and accuracy for all medical conditions.

Overview of Navy Medicine's Limited Duty Patient Population

INTRODUCTION

U.S. Navy Medicine's temporary limited duty (LIMDU) program is the primary vehicle for managing the medical care and subsequent career outcomes of the ill and injured active component (AC) Sailors and Marines to ensure a medically ready force. Before the LIMDU Sailor and Marine Readiness Tracker System (SMART) came online, it was very difficult to examine LIMDU program administration metrics, patients' experiences during LIMDU, and their subsequent health and career outcomes. This study examined the LIMDU patient population's demographic, military career, and LIMDU-specific characteristics; identified characteristics that differed significantly by military service; and evaluated potentially modifiable factors associated with patient outcomes.

MATERIALS AND METHODS

A comprehensive SMART extract was used to identify all AC Sailors and Marines in active LIMDU status between October 1, 2016, and September 30, 2019. The SMART extract was merged with comprehensive administrative military personnel data by patient identifiers to create a longitudinal dataset and to conduct descriptive statistics, bivariate, and multivariate logistic regression analyses for this study. The sample included 26,591 AC Sailors and Marines with complete SMART and military personnel records who ended LIMDU on or before September 30, 2019.

RESULTS

During the study's 3-year period, Navy Medicine's rate of initial LIMDU entry by AC personnel increased each year from 2,041 in FY2017 to 2,424 in FY2019 per 100,000 personnel. At the time of initial entry, most LIMDU patients were male (76%), E4-E6 paygrades (54%), and had a single diagnosis recorded in their SMART records (66%). Pain patients (23%) constituted the largest diagnostic group, followed closely by musculoskeletal patients (23%), and then mental and behavioral health patients (20%). Variables that might reflect administration practices of the program did not differ significantly by service, suggesting good internal standardization of LIMDU administration across Navy Medicine. However, bivariate and multivariate analyses identified significant differences by service for almost all personal demographic, LIMDU-specific, and post-LIMDU military career sample characteristics measured at the last LIMDU close date or later. Study results suggested that the Navy and Marine Corps referred Sailors and Marines to start LIMDU for different medical reasons; to receive care from different military treatment facilities; to close LIMDU with different final actions; and to experience different post-LIMDU career outcomes.

CONCLUSION

Navy Medicine's SMART data is an important new resource for LIMDU program evaluation and population-level patient research, despite the data limitations and concerns identified and addressed by this study. The study results provide a baseline empirical understanding about the LIMDU patient population. Further research is necessary to interrogate the validity of these results over a longer period and to initiate other lines of inquiry. While the construction of the larger project's LIMDU patient population longitudinal dataset required a significant initial investment, future dividends from ongoing work are anticipated. Results derived from verified SMART data will benefit Navy Medicine, operational commands, and LIMDU patients alike by informing continuing efforts to improve patient health and career outcomes, identify and implement best clinical and administrative practices, and optimize force readiness.

The Fascial Distortion Model in Military Aircrew with Chronic Neck Pain: A Case Study

Musculoskeletal pain can be a significant safety risk to aircrew. Flight surgeons are the primary care providers for aircrew and are responsible for safely treating musculoskeletal pain. Certain medical interventions can be used to treat pain while maintaining the ability to fly safely. A previous F-18 Naval Flight Officer presented to the flight surgeon with chronic neck pain seeking noninvasive and nonpharmacological therapy. After one Osteopathic Manual Treatment session using the Fascial Distortion Model (FDM), the patient had improved pain and function. The aircrewman reported an 83% reduction in pain and a 200% improvement in cervical Range of Motion (ROM) immediately following treatment. Neck pain is a common complaint in aircrew. This pain can become an in-flight distraction, thus increasing the risk of aviation mishaps. FDM can decrease pain and increase ROM quickly, without equipment or a large amount of space and without the use of medications that may prohibit an aircrew member from flying. This case study shows the ability to treat a uniformed aircrewman with neck pain while onboard an aircraft. FDM is a technique that can be taught to all flight surgeons. Teaching future flight surgeons FDM techniques can improve the U.S. Navy's resources by decreasing time away from work along with decreasing medical costs. The use of osteopathic manipulation treatment significantly reduced an aircrewman's pain and increased ROM with one treatment while maintaining flight status per current aeromedical waiver guidelines.

Barriers and facilitators to implementation of musculoskeletal injury mitigation programmes for military service members around the world: a scoping review

INTRODUCTION

Musculoskeletal injury (MSK-I) mitigation and prevention programmes (MSK-IMPPs) have been developed and implemented across militaries worldwide. Although programme efficacy is often reported, development and implementation details are often overlooked, limiting their scalability, sustainability and effectiveness. This scoping review aimed to identify the following in military populations: (1) barriers and facilitators to implementing and scaling MSK-IMPPs; (2) gaps in MSK-IMPP research and (3) future research priorities.

METHODS

A scoping review assessed literature from inception to April 2022 that included studies on MSK-IMPP implementation and/or effectiveness in military populations. Barriers and facilitators to implementing these programmes were identified.

RESULTS

From 132 articles, most were primary research studies (90; 68.2%); the remainder were review papers (42; 31.8%). Among primary studies, 3 (3.3%) investigated only women, 62 (69%) only men and 25 (27.8%) both. Barriers included limited resources, lack of stakeholder engagement, competing military priorities and equipment-related factors. Facilitators included strong stakeholder engagement, targeted programme design, involvement/proximity of MSK-I experts, providing MSK-I mitigation education, low burden on resources and emphasising end-user acceptability. Research gaps included variability in reported MSK-I outcomes and no consensus on relevant surveillance metrics and definitions.

CONCLUSION

Despite a robust body of literature, there is a dearth of information about programme implementation; specifically, barriers or facilitators to success. Additionally, variability in outcomes and lack of consensus on MSK-I definitions may affect the development, implementation evaluation and comparison of MSK-IMPPs. There is a need for international consensus on definitions and optimal data reporting elements when conducting injury risk mitigation research in the military.

Designing Implementation Strategies for a Digital Suicide Safety Planning Intervention in a Psychiatric Emergency Department: Protocol for a Multimethod Research Project

BACKGROUND

Suicide prevention is currently a national health priority in Canada. Emergency departments (EDs) are critical settings for suicide prevention, and in our local psychiatric ED at the Centre for Addiction and Mental Health, we plan to embed an app-based tool called the Hope app to support suicide safety planning intervention. The app is free and available on app stores, and usability tests have been completed. As a next step to embed this new tool into the routine clinical workflow, research is needed to assess determinants of and design strategies for implementation with the end goal of routinization.

OBJECTIVE

The purpose of this 2-phased research is to implement the app in the routine clinical workflow in our local psychiatric ED. The specific objectives are as follows: (1) understanding ED clinicians' perceptions and experience of implementing the app in routine practice and identifying barriers to and facilitators of implementation (phase 1) and (2) using findings and outputs from phase 1 and collaborating with service users, families, and ED clinicians to co-design implementation strategies for the app (phase 2).

METHODS

We will use an integrated knowledge translation approach throughout this project. In phase 1, we will conduct interviews with ED clinicians to identify implementation determinants using a behavior change framework. In phase 2, a co-design team comprising clinicians, ED service users, and families will design implementation strategies that align with the determinants identified in phase 1.

RESULTS

This protocol presents detailed information about the entire structure of the 2-phased research project. Ethics approval for conducting the qualitative descriptive study (phase 1) has been obtained, and the recruitment and data collection processes will be completed no later than December 2023. Ethics approval for phase 2 is underway.

CONCLUSIONS

Involving multiple knowledge user groups early in the research and decision-making process is crucial for successful implementation. Although co-designing is commonly practiced during innovation development, there is often a misconception that the responsibility for implementing what has been designed falls on others. This research aims to fill this methodological gap in the health informatics literature. By the end of this project, we will have developed theory-informed implementation strategies to support Centre for Addiction and Mental Health ED clinicians in adopting the Hope app to complete safety planning intervention. These strategies, guided by a behavior change framework, will target clinicians' behavior change and seamlessly integrate the app into the routine clinical workflow. In addition, this research project will provide recommendations on how to involve multiple knowledge user groups and offer insights into how the methodology used can be adapted to other areas within the health informatics literature.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50643.

Clinicians' perspectives on planned interventions tested in the Otago MASTER feasibility trial: an implementation-based process evaluation study

OBJECTIVES

This study reports a process evaluation of the Otago MASTER (MAnagement of Subacromial disorders of The shouldER) feasibility trial. This mixed-methods, process evaluation study was conducted parallel to the Otago MASTER feasibility trial. Our aims were to investigate: (1) supervised treatment fidelity of the interventions and (2) clinicians' perceptions of the trial interventions through a focus group.

DESIGN

Nested process evaluation study using a mixed-methods approach.

SETTING

Outpatient clinic.

PARTICIPANTS

Five clinicians (two men, three women) aged 47-67 years, with clinical experience of 18-43 years and a minimum of postgraduate certificate training, were involved with the delivery of interventions within the feasibility trial. We assessed treatment fidelity for supervised exercises through audit of clinicians' records and compared those with the planned protocol. Clinicians took part in a focus group that lasted for approximately 1 hour. The focus group was transcribed verbatim and focus group discussion was analysed thematically using an iterative approach.

RESULTS

The fidelity score for the tailored exercise and manual therapy intervention was 80.3% (SD: 7.7%) and for the standardised exercise intervention, 82.9% (SD: 5.9%). Clinicians' perspectives about the trial and planned intervention were summarised by one main theme 'conflict experienced between individual clinical practice and the intervention protocol', which was supported by three subthemes: (1) programme strengths and weaknesses; (2) design-related and administrative barriers; and (3) training-related barriers.

CONCLUSION

This mixed-methods study assessed supervised treatment fidelity of interventions and clinicians' perceptions on planned interventions tested in the Otago MASTER feasibility trial. Overall, treatment fidelity was acceptable for both intervention arms; however, we observed low fidelity for certain domains within the tailored exercise and manual therapy intervention. Our focus group identified several barriers clinicians faced while delivering the planned interventions. Those findings are of relevance for planning the definite trial and for researchers conducting feasibility trials.

TRIAL REGISTRATION NUMBER

ANZCTR: 12617001405303.

Inflammatory Arthritis Among Military Servicemen From a Rheumatology Center in Singapore

INTRODUCTION

Musculoskeletal disorders are one of the most common reasons military servicemen seek medical care during their line of duty. This study aims to review the clinical profile and outcomes of military personnel with inflammatory arthritis (IA) referred to a specialist rheumatology center in Singapore.

MATERIALS AND METHODS

Consecutive new case referrals from the Singapore Armed Forces medical centers during the study period January 1, 2010, to December 31, 2019, were retrospectively studied.

RESULTS

There were 123 referrals, comprising 112 (91.1%) males, with the majority being Chinese (110, 89.4%). The mean age was 25.5 ± 11.1 years. The most common diagnoses were gout (including chronic tophaceous gout; 34, 27.6%), spondyloarthritis (18, 14.6%), palindromic rheumatism (8, 6.5%), rheumatoid arthritis (4, 3.3%), and juvenile idiopathic arthritis (4, 3.3%). Among servicemen with gout, all were male, the majority (31, 91.3%) were Chinese, and mean age was 34.1 ± 8.8 years. Mean body mass index (BMI) was 27.5 ± 3.9 kg/m2, of which 41.2% had moderate-risk and 47.1% high-risk BMI for cardiovascular disease and diabetes mellitus (DM). Comorbidities included hyperlipidemia (14), hypertension (6), and type 2 DM (3). Urate lowering therapy was initiated in 27 (79.4%) patients, comprising allopurinol (85.2%), probenecid (11.1%), and their combination (3.7%). One patient developed allopurinol-induced hepatitis; none had severe cutaneous adverse reactions. Among the remaining patients with IA, conventional synthetic disease-modifying antirheumatic drugs (DMARDs) used were sulfasalazine (8), methotrexate (4), hydroxychloroquine (4), and leflunomide (2). Biologic DMARDs used in five patients comprised adalimumab (3) and golimumab (2).

CONCLUSION

Servicemen with IA and good functional status can still be physically fit and deployable into certain combat and service support vocations. This will optimize manpower resources in military organizations with a shrinking young workforce.

Development and validation of a military fear avoidance questionnaire

Chronic pain due to musculoskeletal injury is one of the leading causes of disability and reduced combat readiness in the U.S. Army. Unidimensional pain management systems are not effective in addressing the complex phenomenon of pain-related disability. Growing evidence has supported use of the Fear Avoidance Model (FAM) as a suitable model to address pain-related disability and chronicity from a multidimensional pain neuroscience approach. While several fear avoidance measurement tools exist, one that addresses the complexity of the Army environment encouraged the authors to develop and test the reliability and validity of a military specific questionnaire. This study developed and validated an Army specific fear avoidance screening, the Return to Duty Readiness Questionnaire (RDRQ), which subsequently demonstrated good psychometric properties. Reliability coefficients demonstrate high internal consistency values both during pilot study (α = 0.96) and validation study (α = 0.94, ωt = 0.94). A Correlation Coefficient of 0.74 when compared with the Fear Avoidance Components Scale (FACS) suggests good concurrent validity. Future study should include replication in a new army population, investigation of responsiveness, test-retest reliability, structural validity and establishing severity scores with minimal clinically important differences to enhance utility.

One out of four recruits drops out from elite military training due to musculoskeletal injuries in the Netherlands Armed Forces

INTRODUCTION

Musculoskeletal injuries (MSIs) are among the main causes of dropout from military training. The main purpose of this study was to provide an overview of dropout rates and MSI incidence rates during elite military training. Second, this study aimed to explore restricted training days due to MSIs and to describe MSI-care by military physicians.

METHODS

In a retrospective observational study, we collected dropout rates and injury surveillance data from the electronic patient records of two elite units of the Netherlands Armed Forces (NAF): the Royal Netherlands Marine Corps (RNLMC) and the Airmobile Brigade (AMB), from 1 January 2015 until 31 December 2017.

RESULTS

In the RNLMC, total dropout rate was 53.9% and dropout due to MSIs was 23%. The most frequently affected locations were foot, knee and leg. In the AMB total dropout rate was 52.6% and dropout due to MSIs was 25%. In the AMB, the most frequently affected locations were back, knee and leg. Average restricted training days due to MSIs ranged between 8.3 and 20.8 days/injury. MSI-care by military physicians consisted mostly of the provision of injury-specific information and (self-)management options, imposing a specific activity restriction and referral to physiotherapy.

CONCLUSION

Our study findings showed that one out of four recruits who dropout from elite military training in the NAF, do so due to MSIs. Redesigning training programmes with the objective to reduce MSIs should be given high priority, as this may reduce dropout substantially.

Doctors of chiropractic working with or within integrated healthcare delivery systems: a scoping review protocol

INTRODUCTION

Back and neck pain are the leading causes of disability worldwide. Doctors of chiropractic (DCs) are trained to manage these common conditions and can provide non-pharmacological treatment aligned with international clinical practice guidelines. Although DCs practice in over 90 countries, chiropractic care is rarely available within integrated healthcare delivery systems. A lack of DCs in private practice, particularly in low-income communities, may also limit access to chiropractic care. Improving collaboration between medical providers and community-based DCs, or embedding DCs in medical settings such as hospitals or community health centres, will improve access to evidence-based care for musculoskeletal conditions.

METHODS AND ANALYSES

This scoping review will map studies of DCs working with or within integrated healthcare delivery systems. We will use the recommended six-step approach for scoping reviews. We will search three electronic data bases including Medline, Embase and Web of Science. Two investigators will independently review all titles and abstracts to identify relevant records, screen the full-text articles of potentially admissible records, and systematically extract data from selected articles. We will include studies published in English from 1998 to 2020 describing medical settings that have established formal relationships with community-based DCs (eg, shared medical record) or where DCs practice in medical settings. Data extraction and reporting will be guided by the Proctor Conceptual Model for Implementation Research, which has three domains: clinical intervention, implementation strategies and outcome measurement. Stakeholders from diverse clinical fields will offer feedback on the implications of our findings via a web-based survey.

ETHICS AND DISSEMINATION

Ethics approval will not be obtained for this review of published and publicly accessible data, but will be obtained for the web-based survey. Our results will be disseminated through conference presentations and a peer-reviewed publication. Our findings will inform implementation strategies that support the adoption of chiropractic care within integrated healthcare delivery systems.

Using network analysis to explore factors moderating the implementation of a medication review service in community pharmacy

BACKGROUND

Implementation factors are hypothesised to moderate the implementation of innovations. Although individual barriers and facilitators have been identified for the implementation of different evidence-based services in pharmacy, relationships between implementation factors are usually not considered.

OBJECTIVES

To examine how a network of implementation factors and the position of each factor within this network structure influences the implementation of a medication review service in community pharmacy.

METHODS

A mixed methods approach was used. Medication review with follow-up service was the innovation to be implemented over 12 months in community pharmacies. A network analysis to model relationships between implementation factors was undertaken. Two networks were created.

RESULTS

Implementation factors hindering the service implementation with the highest centrality measures were time, motivation, recruitment, individual identification with the organization and personal characteristics of the pharmacists. Three hundred and sixty-nine different interrelationships between implementation factors were identified. Important causal relationships between implementation factors included: workflow-time; characteristics of the pharmacy-time; personal characteristics of the pharmacists-motivation. Implementation factors facilitating the implementation of the service with highest centrality scores were motivation, individual identification with the organization, beliefs, adaptability, recruitment, external support and leadership. Four hundred and fifty-six different interrelationships were identified. The important causal relationships included: motivation-external support; structure-characteristics of the pharmacy; demographics-location of the pharmacy.

CONCLUSION

Network analysis has proven to be a useful technique to explore networks of factors moderating the implementation of a pharmacy service. Relationships were complex with most implementation factors being interrelated. Motivation and individual identification with the organisation seemed critical factors in both hindering and facilitating the service implementation. The results can inform the design of implementation programs and tailored strategies to promote faster implementation of innovations in pharmacy.

Barriers Perceived by Managers and Clinical Professionals Related to the Implementation of Clinical Practice Guidelines for Breastfeeding through the Best Practice Spotlight Organization Program

International institutions facilitate the contact of health professionals to evidence-based recommendations for promoting exclusive breast feeding (BF). However, the achievement of good rates of exclusive BF is still far from the optimum. The intention of the present work is to determine the barriers identified by managers and health professionals involved in the implementation and sustainability of Clinical Practice Guidelines (CPG) for breastfeeding under the auspices of the Best Practice Spotlight Organization program. A qualitative research study was carried out. The participants were managers, healthcare assistants, nurses, midwives, pediatricians and gynecologists. Semi-structured interviews were conducted which were transcribed and analyzed using the six steps of thematic analysis. Twenty interviews were conducted, which defined four major themes: (1) Lack of resources and their adaptation; (2) Where, Who and How; (3) Dissemination and reach of the project to the professionals; and (4) The mother and her surroundings. This research identifies the barriers perceived by the health professionals involved in the implementation, with the addition of the managers as well. Novel barriers appeared such as the ambivalent role of the midwives and the fact that this CPG is about promoting health. The efforts for promoting the implementation program should be continuous, and the services should be extended to primary care.