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Objective: Ongoing health care reforms within the US Military Health System (MHS) are expected to shift >1.9 million MHS beneficiaries from military treatment facilities (MTFs) into local civilian hospitals over the next 1-2 years. The objective of this study was to examine how such health care reforms are likely to affect the quality of MHS care. Data sources: Adult MHS beneficiaries, aged 18-64 years, treated in MTFs (under a program known as Direct Care) were compared against (1) MHS beneficiaries treated in locally available civilian hospitals (under a program known as Purchased Care) and (2) similarly-aged adult civilian patients across the United States. MHS beneficiaries in Direct and Purchased Care were identified from fiscal-year 2016-2018 MHS inpatient claims. National inpatients were identified in the 2017 Nationwide Readmissions Database. Study design: Retrospective cohort. Data collection: Differences in quality were compared using two sets of quality metrics endorsed by the US Agency for Healthcare Research and Quality (AHRQ): Inpatient Quality Indicators, 19 quality metrics that look at differences in in-hospital mortality, and Patient Safety Indicators, 18 quality metrics that look at differences in in-hospital morbidity and adverse events. Among MHS beneficiaries (Direct and Purchased Care), we further simulated what changes in quality indicators might look like under various proposed scenarios of reduced access to Direct Care. Principal findings: A total of 502,252 MHS admissions from 37 MTFs and surrounding civilian hospitals were included (326,076 Direct Care, 179,176 Purchased Care). Nationwide, 9.34 million adult admissions from 2453 hospitals were included. On average, MHS beneficiaries treated in MTFs experienced better inpatient quality and improved patient safety compared with MHS beneficiaries treated in locally available civilian hospitals (e.g., summary observed-to-expected ratio for medical mortality: 0.98 vs. 1.03, p < 0.001) and adult patients across the United States (0.98 vs. 1.02, p < 0.001). Simulations of proposed changes resulted in consistently worse outcomes for MHS patients, whether reducing MTF access by 10%, 20%, or 50% nationwide; limiting MTF access to active-duty beneficiaries; or closing MTFs with the worst performance on patient safety (p < 0.001 for overall quality indicators for each). Conclusions: Reducing access to MTFs could result in significant harm to MHS patients. The results underscore the importance of health-policy planning based on evidence-based evaluation and the need to consider the consequential downstream effects caused by changes in access to care. KEYWORDS access to care, health care reform, military, Military Health System, MTF Realignment, patient safety, quality, TRICARE What is known on this topic * The US Military Health System (MHS) has long served as a proving ground for theories about the importance of access to care. * In October 2019, major health care reforms within the MHS led to a substantial restructuring of MHS beneficiaries' access to military treatment facilities. What this study adds * Ongoing MHS health care reforms could lead to marked changes in AHRQ-endorsed quality metrics for inpatient quality (Inpatient Quality Indicators) and patient safety (Patient Safety Indicators), resulting in significantly worse care for MHS beneficiaries. * The results underscore the importance of health-policy planning based on evidence-based evaluation and need to consider the consequential downstream effects caused by changes in access to care., 1 | INTRODUCTION As one of the largest health systems in the United States and the single largest provider of government-sponsored universal health insurance coverage for adults aged Since the [...]

Antibiotics and drainage have largely replaced hepatic resection for the treatment of liver abscesses in the modern era; however, in cases caused by a rare strain of Klebsiella pneumoniaewith a hypermucoviscous phenotype, more aggressive hepatic resection may be required. The patient is a 34-year-old male who presented to Landstuhl Regional Medical Center with a week of epigastric pain. His workup revealed a 6 cm liver abscess with growth to 10 cm in 48 hours. He underwent multiple drainage procedures at Landstuhl and then was transferred to Walter Reed where further surgical drainage was performed. Initial cultures demonstrated K. pneumoniae.He clinically improved and was able to discharge after a 2 week hospitalization. His final remaining surgical drain was removed as an outpatient, but 48 hours after removal, he was admitted to the intensive care unit in septic shock. Imaging revealed a 12 cm liver abscess, and cultures verified hypermucoviscous Klebsiella. After multidisciplinary discussion and counseling, he underwent an open right partial hepatectomy. Postoperatively he gradually recovered from his sepsis and major operation and then returned to his home in Landstuhl. This is a case of a rare hypermucoviscous variant of K. pneumoniaecausing a liver abscess resistant to multiple drainage procedures, ultimately requiring open hepatic surgical resection for source control. This remains a last-resort option in the treatment of liver abscesses and should be considered early when caused by this rare strain of Klebsiella.