Analysis of health factors as predictors for the functioning of military personnel: study of the factors that predict fitness for duty and medical costs of soldiers of the Royal Netherlands Army

In 1998, the Royal Netherlands Army introduced a new examination system, which is based on the "workload-capability" model, to replace the old system, which focused on diagnosis and was solely based on the detection of diseases and infirmities. In a randomized controlled study, we found that soldiers recruited under the new system displayed a statistically significant higher number of days fit-for-duty and incurred lower medical costs than solders recruited under the old system. To gain a better understanding of the reasons for these differences, we studied the association between these results and information collected about the soldiers. In the course of the study, we collected various types of information about the study participants (e.g., education, deployment). During the study, soldiers were asked to complete a questionnaire twice a year, its content based in part on a periodic occupational health examination questionnaire commonly used in The Netherlands. We found that the following factors influenced fitness for duty and medical consumption: education, injuries, actual operational deployment, and the examination system itself. The superior performance of the new RNLA Basic Medical Requirements (BMEKL) system seems partly attributable to the assessment of the ability to meet the task-specific requirements. The primary mechanism is as yet undiscovered.     

Difference in fitness for duty among soldiers on a mission: can these be explained by a difference in the preemployment assessment?

In 1998, the Royal Netherlands Army introduced a new examination system (abbreviated as BMEKL), which was based on the "workload-capability" model, to replace the old system (abbreviated as PULHEEMS), which focused on diagnosis and was based solely on the detection of diseases and infirmities. To discern differences under operational conditions between soldiers examined with one of the two medical examination systems, we performed a prospective cohort study. In the study, soldiers who had been declared fit for duty with one of the two medical assessment systems (randomized) and sent on a mission were monitored for 2 years. We used the two operational measures of availability and health care costs. In addition, the candidates were given a questionnaire twice per year during the study period. The study revealed that the soldiers assessed using the function-based BMEKL system displayed greater fitness for duty than did those assessed using the diagnosis-based PULHEEMS system. The BMEKL assessment system is a better predictor of the ability to function as a soldier in general, and with regard to deployment, health, and the locomotor apparatus specifically, than is the PULHEEMS system.     

美军平时医疗保障概况与改革进展

随着近年来美军卫生经费和保障对象健康需求的日益增长,美军平时医疗保障系统不得不采取多项创新性改革措施来控制医疗成本、加强疾病预防和伤员康复,并推行新的初级保健模式,以期在提高医疗保障水平和服务质量的同时有效控制卫生经费。本文主要介绍了美军平时医疗保障体系的概况及最新改革措施与成效。     

The implications of protocol-based care on dental services in the military.

Downsizing, limited resources, and increasing costs provide challenges to the military health system. Variations in the diagnosis and treatment of dental disease add to the demands on the delivery system to provide access and ensure quality for uniformed personnel. Evidence-based dentistry is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. An evidence-based practice combines individual clinical expertise with the best external evidence available from systematic review of research findings. It provides a scientific basis for patient care, planning and implementation of health services, and development of health policy. Practice guidelines formulated on scientific evidence can reduce variations in the diagnosis and treatment of various dental conditions. A risk assessment protocol for treating dental caries can reduce operative dental treatment recommended at the initial examination and decrease the need for restorative care during a military career.     

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.     

Injury prevention during physical activity in the Australian Defence Force

INTRODUCTION: Injuries sustained by Australian Defence Force (ADF) personnel during non-combat military training and sports activity are associated with increasing costs due to work days lost, medical treatment, compensation, and early retirement. In 2001, the ADF commissioned a systematic review of the evidence-base for reducing injuries associated with physical activity, while at the same time improving physical activity participation rates to sustain a trained, fit and deployable workforce. METHOD: Literature from on-line library databases, relevant unclassified military reports, and material from previously published sport-specific injury countermeasure reviews were systematically and critically analysed to address the study aims. RESULTS: Modification of intensity, frequency and duration of basic military training activities and improved equipment is likely to reduce injury occurrence. Sports injury countermeasures used for the civilian population have merit for the ADF physical activity program. Injury countermeasures should be designed to minimise any possible deterrent effect on the motivation to participate in regular physical activity. Increasing the participation of ADF personnel in physical activity in the presence of evidence-based injury prevention strategies has the potential to increase health, fitness and deployability with minimal impact on injury frequency. CONCLUSION: Recommendations arising from the review include injury intervention trials in basic military training and sports. These and other interventions should be supported by refinement to ADF injury surveillance systems. Research should focus on interventions with the greatest gain for fitness, deployability, and cost effectiveness.     

军事医学的系统论证

论文的研究目的是建立军事医学系统论证的科学范式。作者运用系统科学的思想方法,分析了军事医学系统论证的基本要求和特殊要求;研究提出了军事医学战略规划系统论证的指导思想、目标、程序、方法和注意事项;军事医学装备系统论证的目标、工程系统观、综合集成、工作分解结构与系统分析、阶段任务和型号论证;以及军事医学重大项目工程系统论证的论证准则和工程系统分析,并就军事医学战略规划、卫生装备、军用特殊药品研发等系统论证进行了深入探讨。     

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.     

Evaluation of an early discharge program for infants after childbirth in a military population

The objective of this study was to evaluate the outcome of an early discharge program for infants with regard to length of stay, patient safety, maternal satisfaction, and hospital expense in a military population. The study consisted of a retrospective analysis of data from two 6-month periods--March to August 1994 (before early discharge) and March to August 1996 (after early discharge)--in a military, tertiary care, teaching hospital. The criteria for early discharge included healthy term singleton newborns delivered by uncomplicated vaginal delivery with maternal support systems, transportation, and phone access. The interventions included maternal education regarding maternal and infant care and telephone follow-up at 48 hours and 5 days after discharge. The main outcome measures included length of hospital stay, inpatient cost, infant health services utilization, and maternal satisfaction (measured by survey). During the 6-month study periods in 1994 and 1996, a total of 1,911 deliveries were examined. The mean number (+/- SD) of hospital days per infant was 2.54 +/- 0.83 in 1994 compared with 1.88 +/- 1.03 in 1996. There was not a statistically significant difference in the number of readmissions between 1994 (9 of 1042, 0.86%) and 1996 (12 of 869, 1.38%) (odds ratio = 1.61, 95% confidence interval = 0.67, 3.83). A review of the infant health services utilization revealed a statistically significant increase in the total number of clinic visits (scheduled and unscheduled) before the 2-week well-child visit for the 1996 group. However, that group did not experience a change in the number of emergency room visits. Seventy-five percent of mothers were satisfied with the program as assessed by questionnaire. In addition, the program was able to save 599 inpatient hospital days, for a total cost savings of $442,903.23 in 1996. This reduction in inpatient hospital days netted an average cost savings of $509.67 per infant. By following strict discharge criteria, increasing parent education before discharge, implementing a phone follow-up system, and ensuring easy access to care, an early discharge program in our military population was not associated with increased adverse newborn outcomes and reduced costs.     

Comparisons of the interactions of health care delivery and medico-legal practice between Australia and Singapore

Australia and Singapore have similar standards of health care. The one major difference in the two health care systems is the cost to the patient at the point of care. The Medicare system in Australia provides partial to complete subsidy for health care delivery in the public hospitals. In Singapore, the patient has to bear the cost of their health care when needed, with some government subsidies. Studies in the variations between two health care systems, where the costs to the government and individuals are clearly dissimilar, but the health outcomes are similar, can be educational for health law specialists. The methods in which patients obtain recompense for their grievances can help both countries understand how to determine and improve standards of health care communication. Having worked in both systems, the relative values of each and their effects on medical litigation will be discussed.     

Quality control of medical practice in Bophuthatswana

Quality control of medical care in hospitals is an already established monitoring procedure in the United States, enacted by the American Congress as a Public Law. It was adopted and adapted by other Western countries to fulfill its major aim of improving the quality of patient care in hospitals. The various methodologies used so far serve other important purposes as well, i.e., as an education process, a reporting mechanism and to contain the ever increasing costs of medical services. The underlying concept is the legal recognition that the hospital in society exists under "a contract" that requires it to exercise reasonable diligence regarding the quality of medical care to all patients at all times. This concept applies to Bophuthatswana as well. It does so, because one of our major goals is to provide health services to all, as declared by the WHO and UNICEF; and that this goal encompasses many basic human rights which are already in the process of realization. High-quality medical and patient care are two components of this set of rights. However, social priorities here are different from those in developed societies because of socio-economic constraints. Thus, our health policy is unique--primary health care which is hospital-based and community-oriented with the nursing sector at its core. Therefore, our quality control system will be also a unique one and will fit into the specific structure and needs of the health care system and its high ethical approach.     

A review of 10 years of systematic health surveillance in the Army

Health and morbidity reporting has been an important feature of the historical assessment of military campaigns from times of antiquity. Most of these reports have concentrated on hospital admission rates and mortality. In 1994 the British Army introduced a primary care health surveillance reporting system called J94. This provided the first opportunity for the systematic capture and analysis of morbidity data that allowed the identification of disease trends and the audit of remedial action. In parallel with the developments made by the military in the field of health surveillance, a number of initiatives in the NHS tried to develop real time surveillance systems with differing degrees of success. This paper reviews the developments made by military and civilian programs, identifies the problems that have been faced, areas where success has been achieved and the issues that will have to be considered as we prepare for the introduction of the next generation of IT based medical information systems into the military.     

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.     

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.     

Curing America's health care system.

America's health care system is characterized by unacceptably high cost, inequity, and insufficient technology assessment. Cost containment has failed in part because of misunderstanding of the nature of the health care system. Inadequate technology assessment and the malpractice crisis have also contributed to the rise in health care costs. Explicit, systematic rationing of health care services is one way to radically alter the existing system; the instituting of some type of national health program is another. Less drastic measures include systematic technology assessment; growing emphasis on group medical practice; more preventive services; and malpractice reform, including exploration of no-fault legislation and an expanded federal role.     

Military health system efficiency: a review of history and recommendations for the future

This article reviews the history of measuring military medical health care efficiency. No single approved definition or uniform framework has ever been offered or suggested defining military medical treatment facility efficiency over the last 225 years within the Department of Defense. The purpose of this article is to consolidate much of the existing research on the latent variable of military medical efficiency over the last two centuries, and to provide health care leaders a framework for understanding past and current practices in measuring efficiency in the military health care setting.     

美国空军飞行学员医学选拔标准体系及其对我军的启示

系统了解美国空军飞行学员医学选拔标准情况,全面总结美国空军飞行学员医学选拔标准体系和内容,为我军飞行学员医学选拔标准修订和执行提供参考依据.系统分析美国空军4个飞行学员相关医学选拔标准,对照我军飞行学员医学选拔标准,提出美国空军飞行学员医学选拔标准及持续改进的特点内容,归纳我军飞行学员医学选拔优势和需要改进的主要内容.美国空军飞行学员医学选拔标准体系由《国防部指令》《空军体格检查和标准》《空军医学标准指导》《空军特许飞行指南》4个相互引用、相互补充的标准共同构成,具体指标的制订依据来源于航空医学要求和军事训练需要,修改频率很快,整体上更加突出功能需求,与我军飞行学员医学选拔标准相比体系更完善,形态要求更低、功能评价技术更为先进,放飞和停飞依据更为充分.参照美军标准制订的原则和依据开展相应的科学研究,对眼科、外科等生源影响较大、飞行影响较小的一些标准进行针对性修改,完善相关医学选拔技术手段,对扩大招飞优质生源、提升招飞整体质量具有重要意义.     

Costs of excess body weight among active duty personnel,U.S. Air Force, 1997

Although the increasing public health impact of excess body weight in the U.S. general population has received national attention, the impact of excess body weight among active duty military personnel is unknown. A study was conducted to determine the direct (increased medical care) and indirect (lost workdays) costs of excess body weight among active duty Air Force (ADAF) personnel in 1997. Based on measured height and weight values, in 1997, 20.4% of ADAF men and 20.5% of ADAF women had body weights that exceeded their official maximum allowable weight for height. Total excess body weight-attributable costs were estimated at $22.8 million per year, with annual direct and indirect costs estimated at $19.3 million (approximately 6% of total annual expenditures for ADAF medical care) and $3.5 million, respectively. Attributable lost workdays were estimated at 28,351 per year. Annual excess body weight-attributable costs among ADAF personnel are high, both in dollars and lost duty days.