Finally "deliberate by design": milestones in the delivery of health care for U.S. military family members

The development of medical care for U.S. military families and retirees was serendipitous, a fortunate accident. The formal development of military family medical care required the evolution of three factors: the emergence of a standing army, frontiers to guard, and a peace to defend. These factors were first realized in the late 19th Century, and beginning at that point in U.S. history, seven key years highlight major milestones in the history of military family member medical care. At the same time, these years exemplify changing ideas of disease and of health care and how the physical design of clinics and hospitals reflects and impacts these ideas. The Fort Belvoir Community Hospital, which opens in 2011, exemplifies the Nation's best example of green hospital construction, patient and family centered care, and evidence-based design in a Culture of Excellence that demonstrates that military family medical care is finally "deliberate by design."     

公立医院改革对某驻地军队医院门诊费用的影响

 目的 根据公立医院的改革政策,重点分析其对驻地军队医院门诊医疗费用的影响,为军队医院参与城市公立医院综合改革试点提供决策依据。方法 收集武警江苏总队医院2005—2015年门诊就诊人次,利用SAS 9.3软件对门诊人次构成比、门诊不同身份、费别、性别及年龄患者门诊次均费用进行数据分析与研究。结果 (1)次均费用呈逐年递增趋势,年均增长率为9.7%;(2)门诊患者中地方人员占绝大多数,为95.6%,且地方患者和军队患者的门诊费用差异有统计学意义(Z＝47.2066,P<0.0001);(3)自费患者占门诊例数最多为84.0%,其次为城镇医保患者10.3%,且不同费别患者的门诊费用有统计学差异(χ²=41624.2737,P<0.0001);(4)男性患者占总门诊人次的54.4%,高于女性患者,且不同年份男性与女性构成比差异有统计学意义(CMH＝40.6312,P<0.0001);(5)门诊患者中人数最多的为35~59岁年龄组(49.6%),且不同年份年龄构成比差异有统计学意义(χ²=2701.3116,P<0.0001)。结论 该地区根据实际情况制定的医保政策起到了控制医疗费用过快增长的作用,在国家公立医院改革背景下,军队医院军民融合式发展是解决军队医院发展瓶颈问题的有效形式。     

比较北京市医药分开综合改革对某部队医院的影响和启示

 目的 探索北京市医改新形势下某部队医院发展的差异,为下一步医院发展提供管理依据。方法 分别选取医院医改前后各一个季度的医疗工作量、医疗收入及结构变化数据进行自身同比、环比对照,同时与北京市三级医院整体情况进行比照,在分析医药分开综合改革对医院各项指标数据影响的同时,探索医院发展与北京市三级医院整体发展水平的差异。结果 从工作量来看,医改后北京市三级医院门急诊量普遍下降,但某部队医院下降更为明显;出院人次普遍有所增加,但某部队医院减少明显;医疗收入普遍持平略有增长,但某部队医院医疗收入大幅下降。结论 医药分开综合改革后,某部队医院门诊量、收入结构变化与北京市三级医院整体情况基本一致,但收容、收入变化差异较大,一方面反映出医改结果符合改革的政策导向,达到了预定的目标;另一方面反映出部队医院发展存在特殊问题,结合当前医改、军改双重考验,提示部队医院发展到了转型重塑期,面临新的挑战。     

Branch N 6 of GVKG n. a. N.N. Burdenko celebrates 90th anniversary

This article is devoted to the 90th anniversary of one of the largest military clinics, now--the branch N 6 of the Main Military Clinical Hospital n.a N.N. Burdenko. The institution deployed six day patient facility, where annually reinstate more than 4 thousand patients, which significantly reduces the burden on military hospitals and sanatoriums Defense. Polyclinic every day takes up to 2000 people, more than 60 thousand patients from the military, retirees of the Ministry of Defence and family members, civilian personnel of the Armed Forces, more than 250 thousand people in this category is on the advisory medical support are attached to health care. Admission of patients carry more than 280 physicians 62 specialties, they are helped more than 380 experienced nurses. Expanded and equipped with modern medical equipment 119 therapeutic and diagnostic departments and offices.     

Medical emergencies at a major international airport: in-flight symptoms and ground-based follow-up

BACKGROUND: There is limited recent data about the treatments and outcomes of commercial airline passengers who suffer in-flight medical symptoms resulting in subsequent EMS evaluation. The study objectives are to determine incidence, post-flight treatments, outcomes, morbidity, and mortality of these in-flight medical emergencies (IFMEs). METHODS: A 1-yr retrospective study of emergency medical service (EMS), emergency department (ED), and inpatient hospital records of IFME patients from Chicago O'Hare International Airport was completed. All commercial passengers or crew with in-flight medical symptoms who subsequently activated the EMS system on flight arrival are included in the study. The main outcome measures are: in-flight sudden deaths, post-flight mortality, hospital admission rate, ICU admission rate, ED procedures, inpatient procedures, and discharge diagnoses. RESULTS: There were 744 IFMEs for an incidence of 21.3 per million passengers per year. The hospital admission rate was 24.5%. The ICU admission rate was 5.9%. There were five in-flight sudden deaths and six in-hospital deaths for an overall mortality rate of 0.3 per million passengers per year. Emergency stabilization procedures were required on 4.8% of patients. Cardiac emergencies accounted for 29.1% of inpatient diagnoses and 13.1% of all discharge diagnoses. CONCLUSIONS: The incidence of in-flight medical emergencies is small but these IFMEs are potentially lethal. Although the majority of IFME patients have uneventful outcomes, there is associated morbidity and mortality. These included in-flight deaths, in-hospital deaths, and emergency procedures. Cardiac emergencies were the most common of serious EMS evaluated in-flight medical emergencies.     

A sick child day care unit in a military hospital

Sick child day care units have been developed to provide care for children who are excluded from day care because of illness. We implemented a sick child day care unit at a military hospital. In the first year of operation, 526 children were admitted to the unit, with a daily average of 1.9 children and a range of 0-9 children. The most common admission diagnoses were: otitis media (21.3%), upper respiratory infection (19.4%), gastroenteritis (10.6%), and viral syndrome (10.5%). A sick child day care unit in a military hospital can provide a useful service to dependent children, their parents, and the military.     

Status of trauma care in U.S. Army hospitals

OBJECTIVE: This study documents the recent trends and current state of inpatient trauma care in U.S. Army hospitals. METHODS: Inpatient trauma cases from Army hospitals worldwide from October 1988 through April 2001 were analyzed. Facilities included 3 Certified Trauma Centers (CTCs), 7 non-CTC Army Medical Centers, and 42 Army Community Hospitals. Logistic regression identified mortality risk factors. RESULTS: Overall, the Army treated 166,124 trauma cases, with a mortality rate of 0.8% (trend of 0.66% to 1.18% in fiscal years 1989-2000, p < 0.0001). The number of Army hospitals decreased by 44% and the number of trauma cases decreased by nearly 75%. Injury severity, patient age, hospital trauma volume, beneficiary category, hospital type, and a resource intensity measure were all significantly associated with the probability of death. CONCLUSIONS: The overall trauma mortality rate at Army hospitals during the study period was lower than that reported for civilian trauma centers. However, changes in patient profiles, increased average severity, and decreased trauma volume might have contributed to a 13% increase in mortality rates at CTCs.     

Dental orthopedic service for retirees from MD RF in medical institutions of state and municipal system of healthcare

Financial feasibility study of dental orthopedic service for retirees of Ministry of Defence is analyzed, suggestions about the organization of dental orthopedic service for contingent in medical institution of state and municipal system of healthcare. Information about the number of retirees, index of needs in dental orthopedic service which was 40,29%, information about 2806 prosthodontics oders for retirees in military medical institution, data about the average price of production of dental in different subjects of Russian Federation is the basis of the given research. Algorithm of dental orthopedic service for retirees by stomatologies is suggested.     

Colonoscopy by a family physician: a case series demonstrating health care savings

Army community hospitals (ACHs) without gastroenterologists require civilian referrals for colonoscopy. The purpose of this study was to determine whether a colonoscopy-trained, military family physician (FP) saved health care dollars at an ACH by decreasing outside referrals. We present a chart review of all 182 colonoscopies performed by a FP at an ACH from September 2003 to May 2005. The total facility cost was determined using the cost of personnel, lost clinic hours, equipment, supplies, medications, continuing medical education, missed diagnoses, procedure complications, and need for additional studies. The potential referral cost was determined using local civilian colonoscopy billing codes and TRICARE reimbursement rates for 2004. The total facility cost was $53,517.14 ($294.05 per colonoscopy). The total referral cost would have been $156,197.60 ($858.23 per colonoscopy). Using a FP saved the hospital $102,680.46 ($564.18 per colonoscopy). A colonoscopy-trained FP saved significant health care dollars at an ACH.     

Surgical care in the isolated military hospital

BACKGROUND: To maintain the health of service members and their families throughout the world, the Department of Defense has established several isolated military hospitals (IHs). The operational environment of IHs is such that illness and traumatic injury requiring surgical intervention is common. This study sought to examine the general and orthopedic surgical experience at an IH to determine whether surgical care could be provided in an effective and safe manner. METHODS: All patients evaluated by the general and orthopedic surgeon at Guantanamo Bay Naval Hospital from October 1, 1998, to April 1, 1999, were included in this study. The following data were retrospectively reviewed: patient demographic data, diagnosis, initial and follow-up care, medical evacuation data, operative procedures, and complications. RESULTS: There were 336 patients who presented for surgical evaluation, resulting in 660 follow-up appointments during the study period. There were 31 medical evacuations (3 emergent). The surgical services performed 122 major operative procedures. There were 58 inpatient admissions. There was 1 death, and surgical complications occurred in 2 patients, for an overall morbidity and mortality of 1.4% and 0.7%, respectively. CONCLUSION: Our data show that an IH is capable of providing surgical care, including care for traumatic injuries, in a safe manner. This is the first study that provides objective evidence that general and orthopedic surgery at an IH can be provided within the standard of care.     

Esophagogastroduodenoscopy by a family physician: a case series demonstrating health care savings

Rural Army community hospitals without gastroenterologists require civilian referrals for esophagogastroduodenoscopies (EGDs). The goal was to determine whether an endoscopy-trained, military family physician saved health care dollars at an Army community hospital by decreasing outside referrals. We present a chart review of all 95 EGDs performed by a family physician at an Army community hospital between September 2003 and May 2005. The total facility cost was determined by using the cost of personnel, lost clinic hours, equipment, supplies, medications, continuing medical education, missed diagnoses, procedure complications, and need for additional referrals. The potential referral cost was determined by using local civilian endoscopy billing codes and TRICARE reimbursement rates for 2004. The total facility cost was $22,655.65 ($238.48 per EGD). The total referral cost would have been $55,614.95 ($585.42 per EGD). Using a family physician saved the hospital $32,959.30 ($346.94 per EGD). An endoscopy-trained family physician saved significant health care dollars at an Army community hospital.     

绩效考核评价体系在公立医院经营管理中的应用分析

目的：探讨绩效考核评价体系在公立医院经营管理中的应用价值。方法选取30所公立医院,自2011年1月～2013年12月均采取绩效考核评价系统为其经营管理手段,获取医护工作者的综合素质水平及医院的整体效益。结果公立医院通过运用绩效考核评价系统经营管理,医护工作者的综合素质水平较之前提高30％;医院的整体效益上升45％。结论公立医院经营管理中采用绩效考核评价系统,能显著提高医护工作者的综合素质水平及医院的整体效益,改善公立医院的医疗服务水平,为国家医疗卫生事业的进步产生了重大的推动作用。     

Ethnoracial Disparity in Hospital Survival following Transjugular Intrahepatic Portosystemic Shunt Creation for Acute Variceal Bleeding in the United States

PurposeTo investigate the magnitude of racial/ethnic differences in hospital mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation for acute variceal bleeding and whether hospital care processes contribute to them.MethodsPatients aged ≥18 years undergoing TIPS creation for acute variceal bleeding in the United States (n = 10,331) were identified from 10 years (2007–2016) available in the National Inpatient Sample. Hierarchical logistic regression was used to examine the relationship between patient race and inpatient mortality, controlling for disease severity, treatment utilization, and hospital characteristics.ResultsA total of 6,350 (62%) patients were White, 1,780 (17%) were Hispanic, and 482 (5%) were Black. A greater proportion of Black patients were admitted to urban teaching hospitals (Black, n = 409 (85%); Hispanic, n = 1,310 (74%); and White, n = 4,802 (76%); P < .001) and liver transplant centers (Black, n = 215 (45%); Hispanic, n = 401 (23%); and White, n = 2,267 (36%); P < .001). Being Black was strongly associated with mortality (Black, 32% vs non-Black, 15%; odds ratio, 3.0 [95% confidence interval, 1.6–5.8]; P = .001), as assessed using the risk-adjusted regression model. This racial disparity disappeared in a sensitivity analysis including only patients with a maximum Child-Pugh score of 13 (odds ratio 1.2 [95% confidence interval, 0.4–3.6]; P = .68), performed to compensate for the absence of Model for End-stage Liver Disease scores. Ethnoracial differences in access to teaching hospitals, liver transplant centers, first-line endoscopy, and transfusion did not significantly contribute (P > .05) to risk-adjusted mortality.ConclusionsBlack patients have a 2-fold higher inpatient mortality than non-Black patients following TIPS creation for acute variceal bleeding, possibly related to greater disease severity before the procedure.     

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.     

An evaluation of prenatal care utilization in a military health care setting

An assessment of prenatal care and birth outcomes was performed for a sample of 7,599 births at a military hospital between 1982 and 1985. Prenatal care patterns were similar to a civilian Health Maintenance Organization study's. Less adequate levels of prenatal care were significantly associated with higher risks of neonatal mortality and low birth weight. Five independent risk factors for receiving less adequate care were identified by multivariate analysis: 1) young maternal age (less than age 20), 2) black race, 3) residence off post, 4) high risk combinations of age and parity, and 5) residence in low-income census tracts.     

A model program: stress management unit--a clinic run by army nurses.

People suffering from stress and stress-related disorders are a great challenge to our already depleted military health care system. Early identification and separation of soldiers not able to adjust, immediate intervention for temporarily stressed soldiers, and stress management for dependents and retirees help decrease visits to military hospitals and clinics. Immediate intervention for salvageable soldiers also helps improve work performance and productivity. A Stress Management Unit has been open for two years at Brooke Army Medical Center (BAMC), Texas. This article identifies the need for stress management clinics in the military and briefly describes the nurse-run program at BAMC.     

In-hospital morbidity and mortality after endovascular treatment of unruptured intracranial aneurysms in the United States, 1996-2000: effect of hospital and physician volume

BACKGROUND AND PURPOSE: Endovascular therapy is increasingly being used for the treatment of unruptured intracranial aneurysms. Our purpose was to determine the risk of adverse outcomes after contemporary endovascular treatment of unruptured intracranial aneurysms in the United States. Patient, treating physician, and hospital characteristics were tested as potential outcome predictors, with particular attention paid to volume of care. METHODS: We conducted a retrospective cohort study by using the Nationwide Inpatient Sample, 1996-2000. Multivariate logistic and ordinal regressions were used with end points of mortality, discharge other than to home, length of stay, and total hospital charges. RESULTS: Four hundred twenty-one patients underwent endovascular treatment at 81 hospitals. The in-hospital mortality rate was 1.7%, and 7.6% were discharged to institutions other than home. Analysis was adjusted for age, sex, race, primary payer, year of treatment, and four variables measuring acuity of treatment and medical comorbidity. Median annual number of unruptured aneurysms treated was nine per hospital and three per treating physician. Higher volume hospitals had fewer adverse outcomes; discharge other than to home occurred after 5.2% of operations at high volume hospitals (>23 admissions per year) compared with 17.6% at low volume hospitals (fewer than four admissions per year) (P<.001). Higher physician volume had a similar effect (0% versus 16.4%, P=.03). The mortality rate was lower at high volume hospitals (1.0% versus 3.7%) but not significantly so. At high volume hospitals, length of stay was shorter (P<.001) and total hospital charges were lower (P<.001). CONCLUSION: For patients with unruptured aneurysms treated in the United States from 1996 to 2000, endovascular treatment at high volume institutions or by high volume physicians was associated with significantly lower morbidity rates and modestly lower mortality rates. Length of stay was shorter and total hospital charges lower at high volume centers.     

Ryazan hospital--80 years

In December 2011 marked 80 years of the founding of the Ryazan garrison hospital, originally housed in two buildings: "Redut housed"--a monument of architecture of the XVIII century and the former almshouses room "for the maimed in the war", was built in 1884 now Ryazan garrison hospital (from 2010--Branch No 6 FSI "in 1586 the district military hospital in the Western Military District", the Defense Ministry of Russia)--a multi-field medical preventive institution on the basis of which soldiers, military retirees, family members and military retirees from Ryazan, Moscow, Tambov regions are treated. Every year more than 7 thousand patients get treatment here. During the counterterrorism operations in Chechnya over 800 wounded were brought to the hospital from the battle area.     

Some sociodemographic and diagnostic characteristics of military patients treated in the Department of Medical Oncology, Gülhane Military Medical Academy

Today, chronic diseases have increased importance. Cancer, for which 10 million new cases are diagnosed around the world each year, is in the lead of such diseases. This study included military personnel with cancer who applied to the Department of Medical Oncology, Gülhane Military Medical Academy, in the period between 1998 and 2003, and it aims to describe some sociodemographic and diagnostic characteristics of the patients. The total number of cases was 938, which included both active duty and retired military personnel with diagnoses of cancer who were given medical care between 1998 and 2003 in the Department of Medical Oncology. For the study group, the five most common diagnoses were lung cancer, colorectal cancer, testicular cancer, non-Hodgkin's lymphoma, and Hodgkin's disease. Although the first three diagnoses among officers were lung cancer, testicular cancer, and Hodgkin's disease, those among retired officers were colorectal cancer, lung cancer, and prostate cancer. Among noncommissioned officers, the first three diagnoses were colorectal cancer, testicular cancer, and Hodgkin's disease for active duty patients and lung cancer, colorectal cancer, and gastric cancer for retired patients. In the group of privates, testicular cancer, Hodgkin's disease, and non-Hodgkin's lymphoma were the first three diagnoses. When we consider the characteristics of cancers, such as high costs of treatment, loss of manpower, and high mortality rates, prevention of cancers and early diagnosis are very important. Because the frequent types of cancers differed for groups according to age and occupation, those characteristics should be considered when cancer screening programs are being developed for the Armed Forces.     

Outsourcing of primary care: satisfaction level in the Israeli Defense Forces

OBJECTIVE: To examine the effect of outsourcing primary care services on satisfaction levels among career soldiers in the Israeli Defense Forces (IDF). METHODS: Data were acquired via self-administered satisfaction questionnaires during the visits of soldiers and civilians to primary care clinics in military bases, hospitals, and HMO settings. Multivariable analyses (GLM) used the SAS statistical program. RESULTS: Two hundred thirty civilians and 618 soldiers (200 in hospital clinics, 277 in military clinics, and 141 in HMO clinics) completed 848 questionnaires. Gender did not influence satisfaction level (alpha < 0.05). Age and rank influenced two parameters: surroundings (p = 0.0277) and availability of the medical service (p = 0.0368). Location (hospital clinic, HMO clinic, and military clinic) was the primary variable influencing and predicting satisfaction level (11.6%). "Quality of medical care" predicts only 4% of satisfaction level. Soldiers in HMO settings expressed a higher degree of satisfaction particularly in availability of service, quality of service, general satisfaction, and courtesy. CONCLUSIONS: Career soldiers in Israel value all aspects of primary care given by a civilian HMO and are willing to accept a change (outsourcing primary care to a civilian provider). As a result, decision makers should expand the provision of these services to all career soldiers in Israel. Outsourcing of medical services can serve as a model to military corps worldwide.