Quality assessment in primary military clinics of the Israel Defense Forces Northern Command

OBJECTIVE: To assess the quality of care provided in primary military clinics. METHODS: A standardized assessment tool was used, with medical record audits and tracers (minimal clinical criteria for proper care of common conditions), peer-review observations of medical encounters, assessments of organization and administration, and patient satisfaction and physicians' occupational stress questionnaires. RESULTS: Forty-three clinics and 113 physicians were assessed. Tracers were high for management of upper respiratory infections and low for low back pains and mental problems. The average encounter time was 9 minutes, and 25% of medical encounters resulted in referrals to specialists. Regular physicians performed better than reservists. Surgeons performed worst as primary health care providers. Female physicians did better than male physicians. The integration of new immigrant physicians was successful, and they expressed less occupational stress. Smaller clinics were better, with longer encounter times and better patient satisfaction scores. CONCLUSIONS: Quality assessment of primary health care is feasible in the military system, providing useful information for future improvement.     

Development of a deployment course for graduating military internal medicine residents

Graduates of military internal medicine residency programs are required to have the necessary knowledge and skills to function as internists, military physicians, and military medical leaders. The global war on terrorism has increased the role internists are playing in combat theaters as they fill multiple different military medical positions including battalion, brigade, and division surgeons as well as physicians in echelon I, II, and III medical facilities. Along with general internists, internal medicine subspecialists, pediatricians, and family physicians also fill these roles. Although internal medicine training provides a broad-based knowledge to care for adults, it does not provide significant training in combat casualty care, detainee health care, or environmental health. To overcome many of these perceived shortfalls, we developed the 3-day deployment course for graduating internal medicine residents outlined in this article. Through a combination of didactic and hands-on training, militarily relevant medical knowledge and skills necessary to function at echelon I and II levels of care were provided. Residents uniformly accepted the course with measurable increase in their fund of knowledge at the completion of the course.     

Organizational characteristics associated with the availability of women's health clinics for primary care in the Veterans Health Administration

OBJECTIVE: Women's health clinics (WHCs) offering integrated primary care (PC) and gender-specific services reduce fragmentation and improve quality of care for women. Our objective was to understand organizational influences on the development of WHCs for PC delivery in Veterans Health Administration (VA) facilities. METHODS: We surveyed PC directors at 219 VA facilities about the presence of separate WHCs for PC and evaluated organizational characteristics (e.g., authority, staffing, and resources) associated with their development. RESULTS: One hundred thirty-three VA medical centers (61%) have established WHCs for PC. VA facilities with WHCs for PC were significantly more likely to have PC leadership distinct from subspecialty care (odds ratio = 3.62; 95% confidence interval, 1.45-9.05). Local PC staff mix, team structure, and resource characteristics were not associated with WHCs. CONCLUSIONS: With the growth of women in the military and, in turn, in the VA, autonomy of PC leadership may drive VA-based innovations in women's health.     

Quality assessment of primary health care in a military setting

PURPOSE: The aim of this study was to analyze the quality of primary care in Israeli Defense Forces primary care clinics and physicians (PCPs) and to test the hypotheses that: (1) the quality of primary care provided in battalions is higher than that provided by other primary care providers and (2) the evaluation of a specific PCP within the framework of the quality assessment program results in an improved score during a second evaluation. METHODS: Teams of two physicians carried out the control process. Each primary care clinic is evaluated in a standardized manner by filling a prospectively established form. Five parameters are examined: (1) direct inspection of the PCP, (2) medical record audit, (3) high-risk patients' management evaluation, (4) evaluation of secondary health care characteristics, and (5) medical staff guidance evaluation. The various clinics and physicians evaluated were classified as: battalion clinics, division and brigade clinics, training center clinics, and home-front clinics. RESULTS: Between the years 1999 and 2001, 149 primary care clinics and 250 PCPs were evaluated. Seventy-four PCPs (29.6%) were evaluated twice. Battalion clinics scored higher than the other clinics. PCPs evaluated twice had significantly better quality assessment results at the second encounter. CONCLUSIONS: Quality of primary health care is the highest in battalion troops clinics. We interpret the increase in quality assessment scores from one examination to the other as an index of improvement resulting from the feedback given to the providers.     

Who sees the young women? A resource-sharing model for providing comprehensive adolescent women's health care

Female adolescents are underserved in military medicine. This article describes an innovation in preventive care created to address the unmet health needs of female adolescents at a large military community hospital. A "Teen Women's Health Clinic" was created through shared resources between the Departments of Pediatrics and Gynecology. Female teenagers visited the clinic for routine gynecologic care, preventive health maintenance, acute care treatment for gynecologic and general complaints, and subspecialty referral consultation for adolescent medicine. The mean appointment fill rate from May 2001 through April 2002 was 93.8% (range, 63-127%). The mean no-show rate was 16% (range, 0-27%). There was minimal cost to the program. Comprehensive teen women's health with acute and preventive adolescent health care is achievable at the community hospital level at little expense through cooperation between departments. The clinic was well attended, on average working near full capacity, with a low no-show rate for teenagers. Reproduction of this model may be achieved throughout the Department of Defense at minimal cost.     

Various contract settings and their impact on the cost of medical services

OBJECTIVES: This study analyzes the effect of outsourcing healthcare on career soldiers in the Israel Defense Forces (IDF) in different settings, so as to develop a model for predicting per capita medical costs METHODS: Demographic information and data on healthcare utilization and costs were gathered from three computerized billing database systems: The IDF Medical Corps; a civilian hospital; and a healthcare fund, providing services to 3,746; 3,971; and 6,400 career soldiers, respectively. Visits to primary care physicians and specialists, laboratory and imaging exams, number of sick-leave days, and hospitalization days, were totaled for men and women separately for each type of clinic. A uniform cost was assigned to each type of treatment to create an average annual per capita cost for medical services of career soldiers. RESULTS: Significantly more visits were recorded to primary care physician and to specialists, as well as imaging examinations by Leumit Healthcare Services (LHS), than visits and tests in hospitals or in military clinics (p < 0.001). The number of referrals to emergency rooms and sick-leave days were lowest in the LHS as compared to the hospital and military clinics (p < 0.001). The medical cost per capita/year was lowest in LHS as well. CONCLUSIONS: Outsourcing primary care for career soldiers to a civilian healthcare fund represents a major cost effective change, lowest consumption and lower cost of medical care. Co-payment should be integrated into every agreement with the medical corps.     

Differences in beneficiary assessments of health care between TRICARE prime and TRICARE prime remote

OBJECTIVES: We examined differences in health care ratings and reported health care experiences for active duty uniform services personnel using health care plans other than military treatment facilities. METHODS: We used a cross-sectional mail survey of a stratified sample of 3,871 beneficiaries enrolled in TRICARE Prime (TP) and TRICARE Prime Remote (TPR). The adjusted plan mean composite and global ratings were compared between TP and TPR participants. RESULTS: There were few significant differences between the two groups. Patient satisfaction was higher when patients chose their providers (TPR), and use of some preventive services was higher in managed-care plans (TP). Respondents in metropolitan locations differed significantly from those in nonmetropolitan locations in ratings of plans, quality of health care received, and access to services. CONCLUSIONS: The military health system is achieving some success in delivering uniform benefits but faces challenges in delivering high-quality uniform benefits in rural communities.     

Optimization of the system of medical service of students of Cadet Schools of the Ministry of Defense of the Russian Federation

One of the factors of the successful military career guidance Cadet schools students is preserving and promoting their health. Medical support of children and adolescents aged 10-17 years should include the full range of medical and preventive measures defined for this group. The state of providing outpatient care for pupils at the Cadet School in St. Petersburg was studied. These results show that full medical care in accordance with the standards can be based only on children's health clinics. It is important that the organization of medical support pupils cadet schools should be cooperate with civilian health care.     

Women veterans' perceptions and decision-making about Veterans Affairs health care

The increase in women in the military is reshaping the veteran population and Veterans Affairs (VA) health care delivery imperatives. To determine women veterans' perspectives and decision-making about VA health care use, we conducted six focus groups (four VA users and two nonusers) and identified key themes. Barriers to VA use for both VA users and nonusers included lack of information about eligibility and available services. Nonusers often assumed the VA did not provide women's health care. All groups emphasized they required a health care system focused on quality and sensitivity to women's health issues. However, users and nonusers differed in perceptions of VA quality. VA environment and quality concerns led many women to limit their VA use to women's clinics. These qualitative findings provide a context to highlight where interventions and policies suggested by quantitative findings should focus. Dissemination of accurate information about VA eligibility and services, and continued responsiveness to women's perceptions of care are indicated.     

Comparison of health care services for career soldiers throughout the world

Health care systems operate differently in every country and are products of historical and political factors. We compared health care systems for career soldiers in various countries with those of the Israel Defense Forces. Questionnaires requesting data regarding military health care services provided in their countries were sent to military attaches serving in Israel. The countries for which data were gathered include Argentina, Brazil, Chile, China, England, France, Finland, Germany, Hungary, Israel, Poland, Romania, Spain, and the United States. In most countries, career soldiers receive better health care services than civilians, especially in countries with military rule or under military threat.     

Investigation of the correlation between inappropriate hospitalization and hospital stay rate: an application in medical clinics of a military hospital

BACKGROUND: Medical services play a major role in hospital facilities. Along with the medical applications and diagnoses, physicians affect the hospital costs by 70% to 80%. Therefore, the hospital administrators should establish some systems that can modify the current application models of physicians. OBJECTIVE: This study aimed to investigate the appropriateness of hospitalization days and length of stay of the patients in 13 internal clinics in a military hospital. STUDY DESIGN: 5,205 patient days belonging to 416 patients were evaluated by Appropriateness Evaluation Protocol. Patients' data were retrospectively collected by using a "data collection form" through patients' files and then were evaluated by frequencies and percentage distributions. RESULTS: The unnecessary hospitalization rate and unnecessary stay rate were 4.8% and 15.75%, respectively. The highest unnecessary hospitalization rates were in nuclear medicine (50%). CONCLUSION: It was concluded that the inappropriate hospitalization rate and inappropriate stay rates were 4.8% and 15.75%, respectively.     

Gaps in expectations among clients of secondary medical services in the military system compared with the civilian system as a satisfaction index

The Israel Defense Forces Medical Corps operates a health network for Israel Defense Forces soldiers. Secondary medicine is included in the services to which soldiers are entitled. It is provided to military personnel through two parallel systems: within the Medical Corps specialists' clinics and through the auspices of a number of civilian hospital outpatient clinics. The military medical system, like the civilian medical system, is designed to serve its clientele. One of the indices for ascertainment of satisfaction with medical services is compatibility of client expectations with the service actually received. In this study, we present a gap index that demonstrates that there is gap in satisfaction among soldiers receiving secondary medical services from the military network compared with soldiers who receive secondary medical services from the civilian network. We designed a questionnaire administered to 1,532 soldiers and used 1,359 (89% response rate) for our analysis. The military system provides soldiers with services fully in synch with military regulations. Consequently, in most cases, there is a gap between soldiers' expectations from military medical service and the service they receive in practice-a phenomena that impairs soldier satisfaction. On the other hand, soldiers receiving medical services and treatment from the public civilian system receive, for the most part, service and treatment that meets or even exceeds their expectations because the system operates according to other regulations.     

Satisfaction among soldiers with secondary medical services within military and civilian clinical settings

The medical services system of the Israel Defense Forces (IDF) is founded on a principle that by definition considers it the military's role to maintain the health of its personnel in uniform. The 1994 Compulsory Health Insurance Law, Section 55 addresses health services for soldiers, stating that a soldier is entitled to health services from the Medical Corps of the IDF or an agent operating on its behalf. In the implementation of its responsibilities, the IDF Medical Corps operates an array of medical services, including secondary care. This study deals with the scope of utilization of secondary medical services by IDF personnel visiting military medical clinics and civilian hospital outpatient clinics: their character, the subjective health status of the respondents, and their degree of satisfaction with medical services. The results indicate that most of those seeking medical treatment at military and civilian clinics are not chronically ill. Most consider their health status to be good to excellent, but many of those referred for secondary care--more than half of the respondents who visited military specialist clinics-visited the clinics many times and even visited other clinics. No problem of access to clinics was found, but availability was problematic. There was a marked preference among patients to receive secondary health sevices from outside civilian agents rather than the military system.     

Managing health and finance: challenges, outcome, and control in the Israel Defense Forces

BACKGROUND: The Ministry of Defense budget constitutes 16% of the state budget. The budget for the Ministry of Health and for civilian health care is derived from the state budget. The health care funds receive their budgets from several sources. The capitation formula, which is determined by law, is the main factor that affects the size of the budget each fund receives. OBJECTIVE: The objective of this study is to describe the manner of planning, managing, monitoring, and controlling the budget allocated to medical services, which is a public budget for soldiers. METHODS: Several parameters are suggested for comparison, including the interface with the civilian health system, the method for budgeting a health care system, possible results of managing a medically centered budget, and the possibilities for monitoring the provided services. We also examine the potential for decentralization of authority. CONCLUSIONS: Managing the budget and locating appropriate alternatives, as well as the availability and accessibility of medical services, are important for procurement and for forming contracts with both military and civilian systems. Turnover based on updated information might serve to improve future health services.     

Patient satisfaction in military medicine: status and an empirical test of a model

The Department of Defense (DoD) is concerned about how well military medical treatment facilities in the military health system perform. Patient expectations, attitudes, and health care use have been examined in numerous studies; the results are fairly consistent. Eligible beneficiaries report moderate satisfaction with the health care received. In 1994-2001, annual DoD and monthly ambulatory patient surveys were conducted in military medical treatment facilities. The DoD surveys document how patients perceive the care provided. The obvious research concerns are: requirements for conducting surveys; who should be surveyed: eligible beneficiaries or actual users; when; where; representative sample; how often to conduct assessment; data collection methods; analytic schemes; overall trends; predictors of satisfaction; use of results; and timeliness of findings. This study examines these issues and analyzes raw data from selected annual DoD and monthly ambulatory surveys. The overall level of perceived satisfaction has been "good" over the years surveys were used. The model demonstrated the use of examining demographic and attitudinal components of patient satisfaction in military medical facilities.     

Health care utilization and satisfaction concerning gender-specific health problems among military women

There is growing concern regarding the quality of gender-specific health care for military women in general and for female veterans of the Persian Gulf War in particular. This paper reports on health care utilization rates for gender-specific problems and describes differences in these rates among age, rank, and component groups of a randomly selected sample of military women. Study findings provide preliminary evidence for a closer examination of health care services for women within the armed forces, particularly within specific cohorts, to better target both services and policy.     

A model for marketing in the military health care setting

Current literature demonstrates a lack of discussion relative to the marketing of military health care. This is unfortunate, as marketing should be approached as a valuable tool for showing the quality of work provided by a medical facility and for improving consumer relations. The benefit is a public better educated about the military health services system and more attuned to the rationale behind various types of access and availability decisions. This article provides a marketing process usable by military hospitals and health care organizations.