Comparison of discharge diagnoses and inpatient procedures between military and civilian health care systems.

BACKGROUND: Our goal was to compare the demographics and discharge diagnoses between civilian and military health care systems. METHODS: One year (1997) of data from the Retrospective Case Mix Adjustment System from the Military Health Services System were compared with the most recent (1994) civilian National Hospital Discharge Survey data. RESULTS: Military and civilian inpatient age (52.5 and 52.9 years), gender (54% and 59% female), and ethnic distributions (military: 71% white, 16% African American, 3% Asian American, 10% other; civilian: 65% white, 12% African American, 2.6% Asian American, 1.2% Native American, 18% unclassified) were similar. There were similar rank orderings of diagnosis-related groupings (Spearman's rank correlation = 0.72) and procedures performed during hospitalization (Spearman's rho = 0.74), although the military inpatients yielded a higher proportion associated with pregnancy and strenuous activity (traumatic joint disorders and hernias) than their civilian counterparts. CONCLUSION: The practice content of military and civilian inpatients appear to be more similar than different.     

Multiple-role dilemmas for military mental health care providers

Military psychologists and psychiatrists frequently face ethical quandaries involving boundary crossings, or extratherapy contact, and multiple relationships. A multiple relationship is defined as necessarily engaging psychotherapy patients in nonclinical roles, such as coworker, superior officer, neighbor, or friend. In contrast to their civilian counterparts, military mental health professionals must often engage patients in many different contexts and roles. In this article, we consider the distinctive features of mental health practice in the military and offer military providers several practice guidelines for avoiding harm to patients in military settings. This article is also designed to enhance sensitivity to multiple-role risks among nonpsychiatric providers.     

Patients, diagnoses, and procedures in a military internal medicine clinic: comparison with civilian practices

BACKGROUND: Our goal was to compare the demographic features, diagnoses, and procedures in civilian and military ambulatory internal medicine clinics. METHODS: One year (September 1996 to August 1997) of data from the Ambulatory Data System of the Adult Primary Care Clinic at Madigan Army Medical Center was extracted and compared with the most recent (1995) National Ambulatory Medical Care Survey. RESULTS: A total of 41,374 Madigan patient encounters were compared with civilian data from the National Ambulatory Medical Care Survey. The age distribution was similar, with military patients averaging 53.5 years of age and civilian patients averaging 54.5 years. Military patients were more likely to be female (71 vs. 60%) and were more ethnically diverse (military: 68% white, 17% African American, 7% Hispanic, 7% Asian American, and 1% Native American; civilian: 78% white, 10% African American, 6% Hispanic, 5.9% Asian American, and 0.3% Native American). There were similar rank orderings of the top 189 diagnostic groups seen in each setting (Spearman's rho = 0.87). There were also no differences in the type or rank order of procedures performed between military and civilian internists (p = 0.53). CONCLUSION: The practice content of military and civilian practices appears to be more similar than different.     

Prehospital care and the military.

Significant evolution has occurred in prehospital care over the past decade. Civilian emergency medical service (EMS) systems have become progressively sophisticated. Military systems have tended to maintain a wartime philosophy toward prehospital care, and thus its peacetime ambulance service, at times, is not prepared to provide the same standard of care given by the civilian community. This article reviews the current status of civilian and military EMS and attempts to put in perspective the directions that the military could go to improve on the prehospital care it provides.     

The use of unit watch or command interest profile in the management of suicide and homicide risk: rationale and guidelines for the military mental health professional

Military mental health care professionals have, for decades, recommended that commanders implement a unit watch (now called a "command interest profile" at most Army posts) as a tool for enhancing the safety of personnel in the unit when a soldier presents with suicidal or homicidal ideation. Although these procedures are used extensively in garrison and in operational settings, there exists no specific body of literature or Army publication to offer either a rationale or a set of guidelines for their use. We have successfully used unit watch protocols for years both in the deployment setting and in garrison. This article provides both a rationale and a set of guidelines for their use based on fundamental military psychiatric principles, review of the relevant literature, and anecdotal experience with this intervention. Although further research is indicated, this article provides support for the use of unit watch in military settings.     

Civilian versus military trauma dogma: who do you trust?

Combat trauma differs from its peacetime counterpart by involving a different spectrum of injuries, occurring in austere environments, dealing with mass casualties, and embodying inherent treatment delays. Thus, civilian trauma practices may be inappropriate in certain combat settings. A review of historical as well as current vivilian and military data is presented for four trauma topics (military antishock trousers, wound debridement, colon wounds, fluid resuscitation) in which civilian and military principles have clashed. The following recommendations are made. (1) Military antishock trousers are still useful in a combat setting. (2) Soft-tissue wound management should be directed by the wound rather than by the weapon. (3) Cautious avoidance of colostomy may be indicated in certain wartime colon wounds. (4) The majority of combat casualties require early vigorous fluid resuscitation. When civilian trauma experience challenges military dogma, it must be carefully considered before being applied to a combat setting.     

Diagnoses, demographics, and utilization of care as encountered by three U.S. Navy general medical officers

U.S. Navy general medical officers (GMOs) are physicians serving as general practitioners. Although exceptions exist, most GMOs are not board-certified in a specialty. They are post-graduate year 1 (PGY-1)-trained, state-licensed physicians analogous to civilian general practitioners. We conducted a retrospective study using data generated from patient visits with active duty males and females from June 1 to 30, 1998, to describe diagnoses, demographics, and utilization of care patterns encountered by three PGY-1-trained GMOs at an ambulatory clinic. A total of 781 patient encounters with 123 diagnoses from a patient population of 3,178 were recorded. This is an average of 260 patient encounters per GMO, at a rate of 2.52 patients seen per patient-care hour. Fifty-seven consultations/referrals were requested (7.3% of encounters, 1.8% of the patient population). Personnel assigned to the clinic accounted for 4.2% of visits (2% of the patient population). Patient satisfaction was rated as "excellent" to "satisfactory," and no significant morbidity was observed at 1.5-year follow-up. With PGY-1 training, GMOs provide primary care to a substantial volume of prescreened patients and treat patients with a majority of diagnoses without referral or unacceptable complications. The role of GMOs, and perhaps other physicians without specialty training (i.e., general practitioners), in selected settings seems valid and may have advantageous medicoeconomic implications for military and civilian managed care systems.     

Sleep disorders in a military population

INTRODUCTION: Sleep disorders are common in the civilian population, but little is known about which sleep disorders are common in members of the military. This article compares a group of military personnel referred to our sleep disorders center with a group of civilian controls also referred to our sleep disorders center. METHODS: We analyzed the data of 70 Canadian military personnel and 70 civilian controls matched for age and gender. All subjects had full polysomnography. We compared reasons for referral and final sleep diagnoses for both groups. RESULTS: The mean age of each group was 40.8 +/- 7.0 SD (military) and 40.8 +/- 7.3 SD (civilians), and there were 61 men and 9 women in each group. Both groups were obese (body mass index, 30.2 +/- 5.3 (military) versus 32.5 +/- 6.9 (civilian)). Both groups were also pathologically sleepy during the day (Epworth Sleepiness Score, 10.4 +/- 4.6 (military) versus 11.3 +/- 5.4 (civilian)). The majority of referrals in each group were to rule out a sleep breathing disorder (SBD) (66% military versus 79% civilian, p = not significant). Only military patients were referred to rule out a movement disorder (17.1% military versus 0% civilian; 95% confidence interval of the difference = 8.4%-27.6%, p < 0.05). Fewer military were referred because of excessive daytime sleepiness or insomnia (7.1% military versus 20.0% civilian, 95% confidence interval of the difference = -24.4% to -1.4%, p < 0.05). The most common diagnosis confirmed in both groups was a SBD (53% military, 66% civilian, p = not significant). CONCLUSIONS: The range and distribution of sleep disorders seen in the military population is similar to that in the civilian population. Both groups were overweight and sleepy and were found to have SBD and movement disorders. These findings underscore the importance of diagnosing and treating sleep disorders in both groups. The neurocognitive impairment associated with SBD and movement disorders impacts highly on the ability of these groups to safely perform their jobs.     

Predictors of burnout among military mental health providers

Mental health treatment of military service members places unique demands on providers as their patients experience combat stress. This study assessed levels and predictors of burnout among mental health providers (N = 97) at military facilities, using a self-administered survey of demographic and work-related measures and the Maslach Burnout Inventory. Burnout levels were comparable to studies of civilian mental health providers but were less severe than those of the Maslach Burnout Inventory normative sample. Working more hours, having more patients with personality disorders, increased patient caseloads, female gender, and being a psychiatrist were predictive of higher burnout scores. Having more confidants at work, a greater percentage of patients with traumatic brain injury, more clinical experience, and being a psychologist predicted lower burnout scores. These findings suggest that burnout levels among military providers are similar to those among civilian providers and may be alleviated by interventions targeting general institutional risk factors.     

Skin disease in military personnel

Skin disease, disease of the musculoskeletal system, and respiratory infections are the most frequent reasons for military personnel to seek medical care. The Oslo Military Clinic serves all of the military personnel in Oslo and the surrounding region, including officers and civilian employees. From September 1996 to May 1997, 1,360 patients were diagnosed and treated by the author, and the data are included in the following study. Upper respiratory disease was the primary reason for seeking medical attention in 26% of the patients, 21% visited the clinic because of disease or pain in the musculoskeletal system, and 16% suffered from a skin disease. Apart from the low number of female patients, the patient population and the disease spectrum observed in the military clinic are very similar to those in a general medical practice. Among the 222 patients suffering from a cutaneous disease, eczema (42 patients), allergy (excluding dermatitis) (34 patients), acne vulgaris (23 patients), and sexually transmitted diseases (28 patients) were the most prevalent processes. Other less prevalent skin diseases were fungal infections, herpes simplex infection, nevi, common warts, and superficial bacterial skin infections. Skin diseases seen in one patient only included erysipelas, herpes zoster, dermatitis herpetiformis, and Ehlers-Danlos syndrome. Good clinical skills in dermatology are of paramount importance in military medicine, and if possible, the military should appoint a dermatologist to its medical team to rapidly diagnose and treat the large number of patients with skin disorders.     

Concerns about career stigma by military parents of children with psychiatric illness

Stigma is known to have deleterious effects on individuals with psychiatric disorders as well as their family members. In this study, we examined stigma with regard to career concerns among active duty members of the Air Force with children who have psychiatric disorders. Albeit a weak relationship, a bivariate correlation confirmed a significant relationship between the child's mental health utilization (i.e., severity of illness) and participants concerns about the potential effects on their military (r = 0.423, p < 0.01), as well as civilian (r = 0.353, p < 0.01), careers. These findings indicate that among military members with children who have psychiatric disorders, illness severity significantly relates to concerns about the impact of stigma on careers, particularly military careers.     

特殊作业环境下军人心理健康状况研究

为探讨特殊作业环境对军人心理健康状况的影响作用 ,采用症状自评量表 (SCL 90 )对海军某潜艇基地 12 63人、水面舰艇基地 3 61人以及二炮部队官兵 75 3人进行心理评估 ,并与军人常模和地方常模进行了比较研究。结果显示 ,上述 3种特殊作业环境下军人SCL 90各因子分均显著高于地方常模 ,而且除躯体化因子外 ,其余各项因子得分也明显高于军人常模 ,表明特殊的作业环境确实对军人的心理健康状况产生了广泛性的消极影响。对 3种不同作业环境进行具体比较和分析后发现 ,环境对心理健康的不良影响在海军潜艇部队表现得最为明显 ,提示作业环境的高度封闭性对于个体的心理状态具有较强的影响作用     

Incidence of SLAP lesions in a military population

OBJECTIVES: SLAP (superior labrum anterior and posterior) lesions are a recognised cause of shoulder pain and instability. They can occur following a direct blow, biceps traction and compression injuries, and are commonly seen in overhead athletes. Military personnel are physically active and often subjected to trauma. We assessed the incidence of SLAP lesions within a military population presenting with shoulder symptoms. METHODS: A retrospective review, of all shoulder arthroscopies performed by a single surgeon between June 2003 and December 2004 at a district general hospital serving both a military and civilian population, was undertaken. The presentation and incidence of SLAP lesions were recorded for both military and civilian patients. RESULTS: One hundred and seventy eight arthroscopies were performed on 70 (39.3%) military and 108 (60.7%) civilian patients. The average age was 42.3 (range 17-75), 50 females and 128 males were included. Indications for arthroscopy included pain (75.3%), instability (15.7%), pain and instability (7.9%), or "other symptoms" (1.1%). 39 SLAP lesions (22%) were found and grouped according to the Snyder classification--20.5% type 1, 69.3% type 2, 5.1% type 3, 5.1% type 4. Patients with a history of trauma or symptoms of instability were more likely to have a SLAP lesion (p<0.0001). The incidence of SLAP lesions in the military patients was 38.6% compared to 11.1% in civilian patients (p<0.0001). After allowing for the increased incidence of trauma and instability in the military, SLAP lesions were still more common in the military patients (p<0.001). CONCLUSIONS: There is a higher than average incidence of SLAP lesions in military patients compared to civilian patients. They tend to present with a history of trauma, as well as symptoms of pain and instability. Given the high incidence in military personnel, this diagnosis should be considered in military patients presenting with shoulder symptoms, and there should be a low threshold for shoulder arthroscopy.     

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.     

Oral health disparities between ranks in a military environment: Israel Defense Force as a model

Some studies have demonstrated a relationship between occupational status and position in the workplace to use of dental services and oral health status. Ranks symbolize social status in the military hierarchy, which is different from that accepted in civilian workplace. OBJECTIVE: This study was aimed at analyzing differences between officers and noncommissioned personnel in regard to dental treatment needs and use of dental services. METHODS: One-thousand, one-hundred thirty-nine personnel of the Israel Defense Force were examined, using DMFT (decayed, missing, filled permanent teeth and CPITN (community periodontal index of treatment needs indices to define oral health status. A questionnaire was used to calculate utilization rates. RESULTS: Noncommissioned personnel had on average 50% more unmet caries treatment needs, and 19.1% of them suffered from deep periodontal pockets. No differences were demonstrated in utilization rates CONCLUSIONS: Military rank influences oral treatment needs the way civilian organizational structure does with the exception of utilization rates of dental services.     

Brief interventions to reduce harmful alcohol use among military personnel: lessons learned from the civilian experience

Unhealthy alcohol use is among the leading causes of morbidity and mortality in the United States. Among military personnel, service members between the ages 18 and 25 had a 27.3% prevalence of heavy drinking in the previous 30 days, compared to 15.3% among civilians in the same age group. In the civilian world, > 100 million patients are treated in U.S. emergency departments (ED) annually; 7.9% of these visits are alcohol related. Alcohol is associated with a broad range of health consequences that may ultimately present in the ED setting: traumatic injuries (e.g., motor vehicle crashes, intentional violence, falls); environmental injuries (e.g., frostbite); cardiovascular problems (e.g., hypertension, dilated cardiomyopathy); gastrointestinal disorders (e.g., hepatitis, pancreatitis, gastrointestinal bleeding); neurological problems (e.g., encephalopathy, alcohol withdrawal, withdrawal seizures), as well as psychological problems (e.g., depression, suicide). Seminal work has been done to create behavioral interventions for at-risk drinkers. These motivational interventions have been found to be successful in encouraging clients to change their risky behaviors. We present such a technique, called the Brief Negotiated Interview as performed in a civilian ED setting, in hopes of adapting it for use in the military context. Military health care providers could easily adapt this technique to help reduce risky levels of alcohol consumption among service members, retirees, or military dependents.     

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.     

The stigma of mental health problems in the military

The present review addresses the perceived stigma associated with admitting a mental health problem and seeking help for that problem in the military. Evidence regarding the public stigma associated with mental disorders is reviewed, indicating that the public generally holds negative stereotypes toward individuals with psychological problems, leading to potential discrimination toward these individuals. The internalization of these negative beliefs results in self-stigma, leading to reduced self-esteem and motivation to seek help. Even if soldiers form an intention to seek help for their psychological difficulty, barriers to mental health care may prevent the soldier from receiving the help they need. An overall model is proposed to illustrate how the stigma associated with psychological problems can prevent soldiers getting needed help for psychological difficulties and proposed interventions for reducing stigma in a civilian context are considered for military personnel.     

Medication refusal by psychiatric inpatients in the military.

Military psychiatrists must occasionally treat mentally ill active duty patients who refuse medications. Unlike their civilian counterparts, military psychiatrists have no established procedure to allow for involuntary treatment under non-emergency conditions. The following case and discussion is presented to illustrate how existing guidelines do not allow for optimal care of some of these patients.     

Risk of accidents and occupational diseases among the Finnish Defence Forces

OBJECTIVES: Military activities are often considered more dangerous than civilian work, especially in crisis situations, but peacetime or even peacekeeping conditions have seldom been analyzed in this respect. According to the compensation statistics of the Finnish State Treasury, in 2001, 80% of injuries among military personnel were caused by accidents at work, 15% occurred during commuting to and from work, and 5% were attributable to occupational diseases. RESULTS: The compensated accident frequencies varied between 22 and 26 cases per 1 million work hours during the 1990s. During the past few years, the incidence rate has slightly declined. When accidents among military personnel were considered, most occurred during military exercises (57%), during other work (35%), or during work commuting (9%). One person died in an accident during a military exercise in 2001. On the basis of the data of this study, the hypothesis of a substantially higher risk during peacetime for military work, compared with civilian work, is not defensible. The accident rates in the calendar year 2000 were 25% higher for Finnish civilian work (32 cases per 1 million hours) than for the Finnish Defence Forces (22 cases per 1 million hours).