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Background In the Veterans Health Administration (VHA) there is growing interest in the use of nonpharmacologic treatment (NPT) for low back pain (LBP) as pain intensity and interference do not decrease with opioid use. Objectives To describe overall and facility-level variation in the extent to which specific NPT modalities are used in VHA for LBP, either alone or as adjuncts to opioid medications, and to understand associations between veterans' clinical and demographic characteristics and type of treatment. Research design This retrospective cohort study examined use of opioids and 21 specific NPT modalities used by veterans. Subjects VHA-enrolled Iraq and Afghanistan veterans who utilized care in ("linked" to) 130 VHA facilities within 12 months after their separation from the Army between fiscal years 2008-2011, and who were diagnosed with LBP within 12 months after linkage (n=49,885). Measures Measures included per patient: days' supply of opioids, number of visits for NPT modalities, and pain scores within one year after a LBP diagnosis. Results Thirty-four percent of veterans filled a prescription for opioids, 35% utilized at least 1 NPT modality, and 15% used both within the same year. Most patients with LBP receiving NPT, on average, had moderate pain (36%), followed by low pain (27%), severe pain (15%), and no pain (11%). Eleven percent had no pain scores recorded. Conclusions About 65% of VHA patients with a LBP diagnosis did not receive NPT, and about 43% of NPT users also were prescribed an opioid. Understanding utilization patterns and their relationship with patient characteristics can guide pain management decisions and future study.

Background Studies have examined utilization of health care services by civilian children with chronic conditions but not utilization among child dependents of military personnel. Objective To identify children with chronic conditions among military members and retirees and examine their health care utilization and its association with type of condition. Methods We derived our sample from child dependents ages birth to 18 years of military personnel with health care enrollment in FY2011. We defined chronic conditions based on diagnoses and repeated specialty care visits. We accrued one year of health care utilization for each child starting with the date of first diagnosis that qualified (i.e., 2 + visits). Health care utilization measures were any inpatient stay; number of outpatient visits (excluding emergency department [ED] visits), ED visits, and number of psychotropic and non-psychotropic prescriptions. Results Conditions with the highest prevalence were ADHD/conduct disorders (41.2%), other behavioral health (BH) disorders (30.4%), asthma (25.3%) and arthritis (23.8%). Boys and children ages 6–18 were more likely to have BH conditions. Twelve percent had inpatient stays, 63% used the ED, and mean ED visits was 4.6. The mean outpatient visits was 27.9. Utilization was consistently higher for children with both BH and physical health (PH) conditions, children under age 5 (except for number of psychotropic prescriptions), and those enrolled in the military's Extended Health Care Options (ECHO) program. Conclusions Prevalence and utilization findings provide data for future service planning and highlight subgroups of children with chronic conditions who may need better access to supportive military programs.

Introduction Soldiers are at risk for acute and chronic pain due to the mental and physical challenges of military duties and ongoing training for force readiness. With the burden of pain on any individual attributable across pain sources, a broad perspective that goes beyond prior characterizations of pain is important. We aim to further the understanding of pain's effects among non-deployed active duty soldiers and the Military Health System (MHS), by describing prevalence of 10 painful conditions, reported pain levels, duration of pain and impact of pain on military duty limitations. Methods Data are from the MHS Data Repository including outpatient MHS direct care encounters, claims for outpatient purchased care from civilian providers, and vital records, for all soldiers continuously enrolled in TRICARE and not deployed in FY 2012. Ten pain-related diagnostic categories were conceptually derived for this analysis and identified using ICD-9-CM diagnostic codes. We report the FY 2012 prevalence at the soldier-level (N = 297,120) for each pain category as a primary diagnosis, as well as in any diagnostic position, and at the soldier-level for reported pain level, duration, and military duty limitations. Institutional Review Board approval was obtained prior to analyses. Results Overall, 63% of soldiers had at least one pain diagnosis and 59% had a primary pain diagnosis during FY 2012. Back and neck pain (22%), non-traumatic joint disorders (28%), and other musculoskeletal pain (30%) were the most frequent categories for primary diagnosis. Nearly two-thirds of soldiers had a primary pain diagnosis in more than one category, and 23% in four or more categories. Moderate or severe pain levels were reported at least once during the year by 55% of soldiers who had a primary pain diagnosis. In the subsample of soldiers with primary pain in the first quarter, duration and chronicity of pain diagnoses varied by pain category: the back and neck pain category was the most common for both persistent pain occurring in each quarter of FY 2012 (23%) and chronic pain lasting for at least 3 mo (62%). In most pain categories, the majority of soldiers were released without duty limitations. Conclusion These data provide a deeper understanding of pain diagnoses and burden of pain among active duty soldiers. A substantial proportion of soldiers with pain diagnoses were seen for pain self-reported as only mild, or that did not result in significant restrictions in military duty limitations. However, given the prevalence of multiple pain diagnoses and common reports of moderate or severe pain and long duration, complex interventions may be required to minimize the effect of pain on force readiness. This encounters-based analysis is likely an underestimate of presence of pain, and does not include contextual factors that could better describe the true effect of pain among this population.

This study examines whether the relationship between traumatic brain injury (TBI) and post-deployment binge drinking is independent of screening positive for mental health problems among male and female service members. Data are from the Substance Use and Psychological Injury Combat Study of Army members returning from deployment to Afghanistan or Iraq in fiscal years 2008–2011. The sample consists of 240,694 male and 26,406 female active duty members who completed initial and follow-up questionnaires. The initial questionnaire, completed at the end of deployment, included screens for TBI and mental health problems (post-traumatic stress disorder, depression, harmful thoughts). The dependent variable, frequent binge drinking (six or more drinks on one occasion, at least monthly), was assessed on the follow-up questionnaire on average 3–9 months post-deployment. More than 21% of males and 7% of females reported frequent binge drinking. Male members were more likely to screen positive for TBI, compared with females (7.5% vs. 4.4%). Females with both TBI and mental health positive screens had more than double the risk of frequent binge drinking, compared with those without either problem (15.8% vs. 6.6%), and males with both problems had almost double the risk, compared with males with neither problem (33.6% vs. 19.7%). In multivariable logistic regression models, having a TBI and a comorbid positive mental health screen was associated with increased odds of frequent binge drinking among both males and females (adjusted odds ratio [AOR] = 1.59, CI: 1.50-1.69, and AOR = 2.11, CI: 1.57-2.83, respectively), compared with those with neither condition. More research is needed on the interaction of gender and binge drinking, especially when TBI and mental health problems co-exist.

TRICARE provides health care benefits to nearly two million children of active duty, retired, National Guard, and reserve service members. Child health advocates and congressional reports have raised questions regarding the adequacy of these benefits, compared with other sources of children's health insurance. To help address these questions, we compared TRICARE benefits with benefits from Medicaid and Marketplace plans because they represent alternative sources of coverage for many of the families enrolled in TRICARE. Overall, we found that TRICARE benefits fell in the middle-between Medicaid plans' more comprehensive benefits with no cost sharing and Marketplace plans' more restrictive benefits with higher cost sharing.

An association between combat exposure and postdeployment behavioral health problems has been demonstrated among U.S. military service members returning from Afghanistan or Iraq in predominantly male samples, yet few studies have focused on the experiences of women. Using data from the longitudinal, observational Substance Use and Psychological Injury Combat (SUPIC) Study, we explored the self-report of 4 combat exposure items and postdeployment behavioral health screening results for 42,397 Army enlisted women who had returned from Afghanistan or Iraq from fiscal years 2008 through 2011. We ran multivariate logistic regression models to examine how a constructed composite combat exposure score (0, 1, 2, 3+) was associated with screening positive postdeployment for posttraumatic stress disorder (PTSD), depression, and at-risk drinking among active duty (AD) and National Guard/Reserve (NG/R) women. AD and NG/R women commonly reported being wounded, injured, assaulted, or hurt (17.3% and 29.0%, respectively). In all 6 multivariate models, Army women with any report of combat exposure had increased odds of the behavioral health problem (i.e., PTSD, depression, or at-risk drinking). The magnitude of the association between combat exposure and PTSD was most striking, indicating increased odds of PTSD as combat exposure score increased. AD and NG/R women with a combat exposure score of 3+ had increased odds of PTSD, 20.7, 95% confidence interval (CI) [17.0, 25.1] and 27.8, 95% CI [21.0, 36.9], respectively. Women who report combat exposure may benefit from early prevention and confidential intervention to promote postdeployment health and reduce long-term behavioral health problems.

We estimated the prevalence of select mental health diagnoses (MHDX) and mental health treatment (MHT), and identified characteristics associated with MHT during the pre-deployment year (365 days before deployment) in active duty Army women (N = 14,633) who returned from Iraq or Afghanistan deployments in FY2010. Pre-deployment year prevalence estimates were: 26.2 % for any select MHDX and 18.1 % for any MHT. Army women who had physical injuries since FY2002 or any behavioral health treatment between FY2002 and the pre-deployment year had increased odds of pre-deployment year MHT. During the pre-deployment year, a substantial percentage of Army women had MHDX and at least one MHT encounter or stay. Future research should determine if pre-deployment MHDX among Army women reflect vulnerability to future MHDX, or if pre-deployment MHT results in protection from chronic symptoms.

Little is known about the rates and predictors of substance use treatment received in the Military Health System among Army soldiers diagnosed with a postdeployment substance use disorder (SUD). We used data from the Substance Use and Psychological Injury Combat study to determine the proportion of active duty (n = 338,708) and National Guard/Reserve (n = 178,801) enlisted soldiers returning from an Afghanistan/Iraq deployment in fiscal years 2008 to 2011 who had an SUD diagnosis in the first 150 days postdeployment. Among soldiers diagnosed with an SUD, we examined the rates and predictors of substance use treatment initiation and engagement according to the Healthcare Effectiveness Data and Information Set criteria. In the first 150 days postdeployment 3.3% of active duty soldiers and 1.0% of National Guard/Reserve soldiers were diagnosed with an SUD. Active duty soldiers were more likely to initiate and engage in substance use treatment than National Guard/Reserve soldiers, yet overall, engagement rates were low (25.0% and 15.7%, respectively). Soldiers were more likely to engage in treatment if they received their index diagnosis in a specialty behavioral health setting. Efforts to improve substance use treatment in the Military Health System should include initiatives to more accurately identify soldiers with undiagnosed SUD. Suggestions to improve substance use treatment engagement in the Military Health System will be discussed.

INTRODUCTION: Little is known about long-term prescription opioid utilization in the Military Health System. The objectives of this study were to examine predictors of any prescription opioid receipt, and predictors of long-term opioid utilization among active duty soldiers in the year following deployment. MATERIALS AND METHODS: The analytic sample consisted of Army active duty soldiers returning from deployment to Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn in fiscal years 2008–2014 (N = 540,738). The Heckman probit procedure was used to jointly examine predictors of any opioid prescription receipt and long-term opioid utilization (i.e., an episode of 90 days or longer where days-supply covered at least two-thirds of days) in the postdeployment year. Predictors were based on diagnoses and characteristics of opioid prescriptions. RESULTS: More than one-third of soldiers (34.8%, n = 188,211) had opioid receipt, and among those soldiers, 3.3% had long-term opioid utilization (or 1.1% of the cohort, n = 6,188). The largest magnitude predictors of long-term opioid utilization were receiving a long-acting opioid within the first 30 days of the episode, diagnoses of chronic pain (no specified source), back/neck pain, or peripheral/central nervous system pain, and severe pain score in vital records. CONCLUSIONS: Soldiers returning from deployment were more likely to receive an opioid prescription than the overall active duty population, and 1.1% initiated a long-term opioid episode. We report a declining rate of opioid receipt and long-term opioid utilization among Army members from fiscal years 2008–2014. This study demonstrates that the most important predictors of opioid receipt were not demographic factors, but generally clinical indicators of acute pain or physical trauma.

OBJECTIVE:: To examine whether experiencing a traumatic brain injury (TBI) on a recent combat deployment was associated with postdeployment binge drinking, independent of posttraumatic stress disorder (PTSD). METHODS:: Using the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel, an anonymous survey completed by 28546 personnel, the study sample included 6824 personnel who had a combat deployment in the past year. Path analysis was used to examine whether PTSD accounted for the total association between TBI and binge drinking. MAIN MEASURES:: The dependent variable, binge drinking days, was an ordinal measure capturing the number of times personnel drank 5+ drinks on one occasion (4+ for women) in the past month. Traumatic brain injury level captured the severity of TBI after a combat injury event exposure: TBI-AC (altered consciousness only), TBI-LOC of 20 or less (loss of consciousness up to 20 minutes), and TBI-LOC of more than 20 (loss of consciousness >20 minutes). A PTSD-positive screen relied on the standard diagnostic cutoff of 50+ on the PTSD Checklist-Civilian. RESULTS:: The final path model found that while the direct effect of TBI (0.097) on binge drinking was smaller than that of PTSD (0.156), both were significant. Almost 70% of the total effect of TBI on binge drinking was from the direct effect; only 30% represented the indirect effect through PTSD. CONCLUSION:: Further research is needed to replicate these findings and to understand the underlying mechanisms that explain the relationship between TBI and increased postdeployment drinking. Language: en

Approximately three to six months after returning from deployment, military service members complete the Post-Deployment Health Reassessment (PDHRA), which includes screens for alcohol misuse, depression, and posttraumatic stress disorder (PTSD). To determine whether Army Reserve Component (RC) members (Army National Guard and Army Reserve) with positive screening scores on the PDHRA receive needed care, the investigators examined the association between positive scores and enrollment and utilization of care ("linkage") in the Veterans Health Administration (VHA), as well as rescreening scores, diagnosis, and behavioral treatment in VHA.Mixed-effects regression models were used to predict linkage to VHA within six months after RC members (N=73,164) completed the PDHRA, with alcohol misuse, depression, and PTSD screen scores as key independent variables. Regression models were stratified by gender and National Guard versus Reserve status. Among those who linked to VHA (N=25,168), screening scores and subsequent diagnosis and treatment in VHA were also examined.Army RC members with positive PTSD and depression screening scores were more likely than those with negative screens to link to VHA, and most (54%-84%) received VHA treatment once diagnosed. Positive screens for alcohol misuse were associated with linkage to VHA for men but not for women, and treatment rates for alcohol use disorders were relatively low (0%-25%) for both men and women diagnosed as having an alcohol use disorder.The finding that Army RC members with greater indications of behavioral health problems linked to VHA is encouraging. However, more outreach and treatment engagement strategies could be directed to those with alcohol use disorder, particularly women.

This study described rates and predictors of Army National Guard and Army Reserve members' enrollment in and utilization of Veteran Health Administration (VHA) services in the 365 days following demobilization from an index deployment. We also explored regional and VHA facility variation in serving eligible members in their catchment areas. The sample included 125,434 Army National Guard and 48,423 Army Reserve members who demobilized after a deployment ending between FY 2008 and FY 2011. Demographic, geographic, deployment, and Military Health System eligibility were derived from Defense Enrollment Eligibility Reporting System and "Contingency Tracking System" data. The VHA National Patient Care Databases were used to ascertain VHA utilization and status (e.g., enrollee, TRICARE). Logistic regression models were used to evaluate predictors of VHA utilization as an enrollee in the year following demobilization. Of the study members demobilizing during the observation period, 56.9% of Army National Guard members and 45.7% of Army Reserve members utilized VHA as an enrollee within 12 months. Demographic, regional, health coverage, and deployment-related factors were associated with VHA enrollment and utilization, and significant variation by VHA facility was found. These findings can be useful in the design of specific outreach efforts to improve linkage from the Military Health System to the VHA.

Objectives. We identified to what extent the Department of Defense postdeployment health surveillance program identifies at-risk drinking, alone or in conjunction with psychological comorbidities, and refers service members who screen positive for additional assessment or care. Methods. We completed a cross-sectional analysis of 333 803 US Army active duty members returning from Iraq or Afghanistan deployments in fiscal years 2008 to 2011 with a postdeployment health assessment. Alcohol measures included 2 based on self-report quantity-frequency items—at-risk drinking (positive Alcohol Use Disorders Identification Test alcohol consumption questions [AUDIT-C] screen) and severe alcohol problems (AUDIT-C score of 8 or higher)—and another based on the interviewing provider’s assessment. Results. Nearly 29% of US Army active duty members screened positive for at-risk drinking, and 5.6% had an AUDIT-C score of 8 or higher. Interviewing providers identified potential alcohol problems among only 61.8% of those screening positive for at-risk drinking and only 74.9% of those with AUDIT-C scores of 8 or higher. They referred for a follow-up visit to primary care or another setting only 29.2% of at-risk drinkers and only 35.9% of those with AUDIT-C scores of 8 or higher. Conclusions. This study identified missed opportunities for early intervention for at-risk drinking. Future research should evaluate the effect of early intervention on long-term outcomes.

We compile a new unit-record data set of Australian corporate bond issuance, which sheds light on developments in the bond market since the early twentieth century. Reflecting the evolution of the economy, privatisations, and changes in the regulatory landscape the following trends are noteworthy: (i) issuance today is largely by private entities whereas government-owned corporations dominated historically; (ii) the issuer base has shifted away from non-financial corporations towards banks, with corporations now raising a large share of funds offshore; and (iii) the investor base has shifted away from direct holdings by households towards holdings through superannuation/managed funds and holdings by non-residents.

The Substance Use and Psychological Injury Combat Study (SUPIC) will examine whether early detection and intervention for post-deployment problems among Army Active Duty and National Guard/Reservists returning from Iraq or Afghanistan are associated with improved long-term substance use and psychological outcomes. This paper describes the rationale and significance of SUPIC, and presents demographic and deployment characteristics of the study sample (N = 643,205), and self-reported alcohol use and health problems from the subsample with matched post-deployment health assessments (N = 487,600). This longitudinal study aims to provide new insight into the long-term post-deployment outcomes of Army members by combining service member data from the Military Health System and Veterans Health Administration.

The study objective was to estimate complementary and alternative medicine (CAM) use among active duty military and compare data with civilian use.A global survey on CAM use in the 12 previous months was conducted. Final participants (16,146) were stratified by gender, service, region, and pay grade. Analysis included prevalence of CAM use, demographic and lifestyle characteristics.Approximately 45% of respondents reported using at least one type of CAM therapy. Most commonly used therapies were as follows: prayer for one's own health (24.4%), massage therapy (14.1%), and relaxation techniques (10.8%). After exclusion of prayer for one's own health, adjusting to the 2000 U.S. census, overall CAM use in the military (44.5%) was higher than that in comparable civilian surveys (36.0% and 38.3%).Military personnel reported using three CAM stress-reduction therapies at 2.5-7 times the rate of civilians. Among the military, high utilization of CAM practices that reduce stress may serve as markers for practitioners assessing an individual's health and well-being.

PURPOSE Following the acute phase of treatment, national guidelines recommend cancer survivors have routine contact with health care providers and undergo basic ancillary testing while avoiding high-cost imaging (HCI). We conducted this study to determine how frequently breast, prostate, and colorectal cancer survivors received recommended follow-up care and HCI tests during the survivorship period. METHODS Using administrative data from TRICARE beneficiaries, we identified a cohort of patients who were treated for breast, prostate, or colorectal cancer between October 2005 and March 2007. These patients were then followed through September 2010. During the 3 years after initial treatment, we determined how frequently survivors received all minimum recommended survivorship care as defined by national guidelines and underwent HCI tests and if these outcomes varied by geographic region. RESULTS Overall, 3148 patients underwent treatment for breast (n = 1630), prostate (n = 1173), or colorectal (n = 345) cancer. Sixty-five percent received all minimum recommended care over 3 years (breast = 74.1%, prostate = 65.3%, colorectal = 25.5%). During the 3-year period, 74.1% of breast cancer survivors received a mammogram each year, whereas 69.1% of colorectal cancer survivors had at least 1 colonoscopy. Sixty-four percent had at least 1 HCI study during the 3-year period (positron emission tomography = 10.9%, computer tomography = 48.8%, magnetic resonance imaging = 36.6%) at a cost of $3.5 million. Substantial state-level variation was noted for both outcomes. DISCUSSION Some cancer survivors do not receive recommended care following initial treatment while frequently undergoing HCI. The existing geographic variation in quality and imaging utilization suggests that improvements to cancer survivorship care are possible.

The Hedgehog (Hh) pathway regulates the growth of a subset of adult gliomas and better definition of Hh-responsive subtypes could enhance the clinical utility of monitoring and targeting this pathway in patients. Somatic mutations of the isocitrate dehydrogenase ( IDH ) genes occur frequently in WHO grades II and III gliomas and WHO grade IV secondary glioblastomas. Hh pathway activation in WHO grades II and III gliomas suggests that it might also be operational in glioblastomas that developed from lower-grade lesions. To evaluate this possibility and to better define the molecular and histopathological glioma subtypes that are Hh-responsive, IDH genes were sequenced in adult glioma specimens assayed for an operant Hh pathway. The proportions of grades II–IV specimens with IDH mutations correlated with the proportions that expressed elevated levels of the Hh gene target PTCH1 . Indices of an operational Hh pathway were measured in all primary cultures and xenografts derived from IDH -mutant glioma specimens, including IDH -mutant glioblastomas. In contrast, the Hh pathway was not operational in glioblastomas that lacked IDH mutation or history of antecedent lower-grade disease. IDH mutation is not required for an operant pathway however, as significant Hh pathway modulation was also measured in grade III gliomas with wild-type IDH sequences. These results indicate that the Hh pathway is operational in grades II and III gliomas and glioblastomas with molecular or histopathological evidence for evolvement from lower-grade gliomas. Lastly, these findings suggest that gliomas sharing this molecularly defined route of progression arise in Hh-responsive cell types.

This article describes the reliability of the instruments embedded in a mental health screening instrument designed to detect risky drinking, depression, and post-traumatic stress disorder among members of the Armed Forces. The instruments were generally reliable, however, the risky drinking screen (Alcohol Use Disorders Identification Test-Consumption) had unacceptable reliability (α = 0.58). This was the first attempt to assess psychometric properties of a screening and assessment instrument widely used for members of the Armed Forces.

Summary Background US military suicides have increased substantially over the past decade and currently account for almost 20% of all military deaths. We investigated the associations of a comprehensive set of time-varying risk factors with suicides among current and former military service members. Methods We did a retrospective multivariate analysis of all US military personnel between 2001 and 2011 (n=110 035 573 person-quarter-years, representing 3 795 823 service members). Outcome was death by suicide, either during service or post-separation. We used Cox proportional hazard models at the person-quarter level to examine associations of deployment, mental disorders, history of unlawful activity, stressful life events, and other demographic and service factors with death by suicide. Findings The strongest predictors of death by suicide were current and past diagnoses of self-inflicted injuries, major depression, bipolar disorder, substance use disorder, and other mental health conditions (compared with service members with no history of diagnoses, the hazard ratio [HR] ranged from 1·4 [95% CI 1·14–1·72] to 8·34 [6·71–10·37]). Compared with service members who were never deployed, hazard rates of suicide (which represent the probability of death by suicide in a specific quarter given that the individual was alive in the previous quarter) were lower among the currently deployed (HR 0·50, 95% CI 0·40–0·61) but significantly higher in the quarters following first deployment (HR 1·51 [1·17–1·96] if deployed in the previous three quarters; 1·14 [1·06–1·23] if deployed four or more quarters ago). The hazard rate of suicide increased within the first year of separation from the military (HR 2·49, 95% CI 2·12–2·91), and remained high for those who had separated from the military 6 or more years ago (HR 1·63, 1·45–1·82). Interpretation The increased hazard rate of death by suicide for military personnel varies by time since exposure to deployment, mental health diagnoses, and other stressful life events. Continued monitoring is especially needed for these high-risk individuals. Additional information should be gathered to address the persistently raised risk of suicide among service members after separation. Funding Partly funded by the Naval Research Program.

To identify characteristics associated with testing positive for illicit drugs postdeployment among Army enlisted members.Army active duty and National Guard/Reserve enlisted members returning from Operation Enduring Freedom/Operation Iraqi Freedom deployments in fiscal years 2008 to 2011, who submitted urine specimens for random and other illicit drug tests up to 3 years postdeployment, were included. Multiple logistic regression models, stratified by component, identified demographic and deployment characteristics associated with any positive drug test (cocaine, heroin, tetrahydrocannabinol [marijuana], or amphetamine) during the 3 years postdeployment.Among Army active duty and National Guard/Reserve enlisted members, respectively, 3.46% (95% confidence interval 3.40-3.52) and 3.84% (confidence interval 3.74-3.94) tested positive for 1+ illicit drugs during the 3 years postdeployment; the vast majority for marijuana. Relative to other groups, increased odds of a positive drug test were found for members with a combat specialist occupation, or first deployers.Almost 4% of Army members tested positive for illicit drug use within 3 years of return from deployment. Early identification and intervention with enlisted members who are more likely to test positive for illicit drug use should be explored to see if it will enhance health and reduce illegal drug use after deployment to a war zone.

BACKGROUND U.S. Armed Forces members and spouses report increased stress associated with combat deployment. It is unknown, however, whether these deployment stressors lead to increased dependent medication use and health care utilization. OBJECTIVE To determine whether the deployment of Army active duty members (sponsors) is associated with changes in dependent health care utilization. DESIGN A quasi-experimental, pre-post study of health care patterns of more than 55,000 nonpregnant spouses and 137,000 children of deployed sponsors and a comparison group of dependents. MEASURES Changes in dependent total utilization in the military health system, and separately in military-provided and purchased care services in the year following the sponsors' deployment month for office visit services (generalist, specialist); emergency department visits; institutional stays; psychotropic medication (any, antidepressant, antianxiety, antistimulant classes). RESULTS Sponsor deployment was associated with net increased use of specialist office visits (relative percent change 4.2% spouses; 8.8% children), antidepressants (6.7% spouses; 17.2% children), and antianxiety medications (14.2% spouses; 10.0% children; P

We estimate the effect of deployment location and length on risk of developing post-traumatic stress disorder (PTSD). We draw a random sample of active duty enlisted personnel serving between 2001 and 2006 from a TRICARE beneficiary database and link deployment characteristics from the contingency tracking system. Using logistic regressions, we found that deployment to Iraq/Afghanistan increases the odds of developing PTSD substantially, relative to those in other duties, with the largest effect observed for the Navy (OR = 9.06, p < 0.01) and the smallest effect for the Air Force (OR = 1.25, p < 0.01). A deployment longer than 180 days increases the odds of PTSD by 1.11 to 2.84 times compared to a short tour. For Army and Navy, a deployment to Iraq/Afghanistan further exacerbates the adverse effect of tour length.

Pay-for-performance (P4P) programs are expanding their purview from quality to include efficiency, and many consider the episode of care as the appropriate unit of measurement. Two years' experience by the California P4P program, however, reveals that the requisite claims data often are incomplete or poorly coded and that even large physician groups have too few patients experiencing most types of episodes to permit statistically valid measurement for public reporting and incentive payment. The California P4P program is shifting its efficiency focus to metrics not reliant on episode measurement while shifting episode measurement to supporting bundled payment for acute surgical and medical interventions.

Purpose To describe utilization patterns for anti-diabetes medications among a cohort of diabetes patients in the Military Health System (MHS) before and after warnings about rosiglitazone issued in May 2007. Methods We used segmented regression analysis to compare changes in the level and trend of rosiglitazone utilization and use of other anti-diabetes therapies in the period prior to the drug warnings (between April 2006 and May 2007) and the period after the warnings were issued (between October 2007 and May 2008). Results The level and trend of rosiglitazone use changed after the highly publicized warnings. The number of prescriptions filled fell by almost 7000 after the warning (p

This study described the rate and predictors of Operation Enduring Freedom/Operation Iraqi Freedom active duty Army members' enrollment in and use of Veterans Health Administration (VHA) services (linkage), as well as variation in linkage rates by VHA facility. We used a multivariate mixed effect regression model to predict linkage to VHA, and also calculated linkage rates in the catchment areas of each facility (n = 158). The sample included 151,122 active duty members who deployed to Iraq or Afghanistan and then separated from the Army between fiscal years 2008 and 2012. Approximately 48% of the active duty members separating utilized VHA as an enrollee within one year. There was significant variation in linkage rates by VHA facilities (31-72%). The most notable variables associated with greater linkage included probable serious injury during index deployment (odds ratio = 1.81), separation because of disability (odds ratio = 2.86), and various measures of receipt of VHA care before and after separation. Information about the individual characteristics that predict greater or lesser linkage to VHA services can be used to improve delivery of health care services at VHA as well as outreach efforts to active duty Army members.

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 unifo...

Purpose. To assess the status of U.S. military retirees and their spouses 38 to 64 years of age relative to select Healthy People 2010 objectives and to identify sociodemographic characteristics associated with select health behaviors. Design. Cross-sectional analyses with self-reported standardized measures from the U.S. Department of Defense Population Health Survey, 2003. Setting. The continental United States. Subjects. U.S. military retirees and their spouses 38 to 64 years of age. Measures. Data for this study were self-reported responses to the Population Health Survey. Dichotomous variables were created to indicate whether each Healthy People 2010 objective had been met. Each objective was measurable with the survey by using the definitions set forth in Healthy People 2010. These objectives included healthy weight and obesity based on body mass index (height and weight); daily fruit, vegetable, and grain-product consumption; physical inactivity, moderate physical activity, and vigorous physical activity; binge drinking; cigarette use; and smoking-cessation attempts. Results. The study population did not meet any of the Healthy People 2010 objectives included in this study. Sociodemographic characteristics that were associated with this result included being male, not having a college degree, and a less-than-excellent self-reported general health status. Conclusion. Health-promotion interventions are needed to improve the health status of this population and to achieve the goals set forth in Healthy People 2010.

Background The U.S. Department of Defense provides medical services for approximately 9.1 million beneficiaries, one-half of whom are women. Information is lacking about how well the military health system has adopted patient-centered approaches for promoting individual choice and preference in a bureaucratically structured military hospital. The purpose of this study was to examine women's evaluations of maternity care with respect to decision-making, confidence, trust in health care providers, and treatment within the military hospital. Methods The Department of Defense Inpatient Childbirth Survey was mailed to a simple stratified random sample of beneficiaries who received maternity care at a military hospital between July 1 and September 30, 2001. Data for 11 dimensions of women's care and experiences were examined from self-reported assessments of 2,124 respondents who gave birth at one of 44 military hospitals. A multiple logistic regression model was estimated to determine which dimensions of care predicted beneficiaries' likelihood to recommend the military hospital to family and friends. Result Less than 50 percent of respondents would recommend the military hospital to family and friends. Significantly associated with women's willingness to recommend their specific military hospital to others were courtesy and availability of staff, confidence and trust in provider, treatment with respect and dignity, information and education, physical comfort, involvement of friends and family, continuity and transition, and involvement in decision-making. Conclusions In a military population, obstetric patients who are treated with respect, courtesy, and dignity, are involved in decisions about their care, and have established trusting relationships with their practitioners are significantly more likely to recommend the military hospital to others. It is important for military health care leaders to establish a proactive program of patient-centered maternity care. Continuous care, education, support services, and a multidisciplinary approach should be integrated to retain and recapture obstetric patients who are served in military hospitals in the United States.

Materials and methods Using longitudinal data from The Substance Use and Psychological Injury Combat Study, we identify predictors of testing positive for one or more drugs post-deployment among 306,345 enlisted Army active-duty (AD) members returning from Iraq or Afghanistan in FY2008–2011. Subsample analyses examine findings from those members who completed a follow-up questionnaire approximately 6 months after the deployment (n = 262846). Urinalysis tests for metabolites of cocaine, heroin, THC, and/or amphetamines are routinely and randomly tested by the military’s drug test program. These data were examined to estimate the percent of the sample with any positive drug test 6 months and up to 3 years post-deployment (followup). Demographic and deployment characteristics and self-report of post-deployment problems were examined as potential predictors of a positive drug test.

To calculate the annual rate of psychiatric evacuation of U.S. Service members out of Iraq and Afghanistan and identify risk factors for evacuation.Descriptive and regression analyses were performed using deployment records for Service members evacuated from January 2004 through September 2010 with a psychiatric diagnosis, and a 20% random sample of all other deployers (N = 364,047).A total of 5,887 deployers psychiatrically evacuated, 3,951 (67%) of which evacuated on first deployment. The rate increased from 72.9 per 100,000 in 2004 to 196.9 per 100,000 in 2010. Evacuees were overrepresented in both combat and supporting duty assignments. In multivariate analysis, Army active duty had the highest odds of evacuation relative to Army National Guard (adjusted odds ratio [AOR] 0.852, 95% confidence interval [CI] 0.790-0.919), Army Reserve (AOR 0.825, 95% CI 0.740-0.919), and all other components. Accessions in 2005 had the highest risk (AOR 1.923, 95% CI 1.621-2.006) relative to pre-2001 accessions.Risk for psychiatric evacuation is highest among the Army Active Component. A strong link between multiple deployments or combat-related exposure and psychiatric evacuation is not apparent. Increased risk among post-2001 accessions suggests further review of changes in recruitment, training, and deployment policies and practices.

Hedgehog (Hh) signaling regulates the growth of malignant gliomas by a ligand-dependent mechanism. The cellular source of Sonic Hh ligand and mode of signaling have not been clearly defined due to the lack of methods to definitively identify neoplastic cells in glioma specimens. Using an antibody specific for mutant isocitrate dehydrogenase protein expression to identify glioma cells, we demonstrate that Sonic Hh ligand and the pathway components Patched1 (PTCH1) and GLI1 are expressed in neoplastic cells. Further, Sonic Hh ligand and its transcriptional targets, PTCH1 and GLI1, are expressed in mutually distinct populations of neoplastic cells. These findings support a paracrine mode of intratumoral Hh signaling in malignant gliomas.

BACKGROUND Physicians can provide important information about how managed care plans affect the delivery of health care. Assessments of the quality of managed care plans have rarely used physician evaluations. OBJECTIVES To elicit physician evaluations of managed care plans and to determine factors associated with those evaluations. RESEARCH DESIGN Physicians were asked in a mail survey to evaluate a managed care plan they were associated with. SUBJECTS Probability sample of 1,336 physicians associated with the five largest managed care health plans in Massachusetts. MEASURES Physicians were asked about the extent to which the management strategies used by a plan influenced their clinical behavior and about the quality of care available to their patients. RESULTS Evaluations of the plans were significantly different among the eight units evaluated. Some differences between divisions within plans were as large as differences among plans. Physicians reported that the use of education and peer influence influenced their clinical behavior and facilitated the provision of high quality care more than did rules and regulations or financial incentives. Physicians evaluated most positively plans, which they said used educational strategies more than other plans and which used rules and regulations and financial incentives less. Physicians tended to rate staff and group model plans more positively than did other plans. CONCLUSIONS Physicians can provide important information about the extent to which the organization and operation of managed care plans affect the provision of high quality care.

We consider an analytic survey in which each survey unit can respond with respect to one or more domains to which it belongs. In this situation, the optimal sample allocation is constrained by the number of available units in each stratum defined by a set of domains. We present optimal sample allocation rules for this situation, and other rules that apply when there are additional constraints on sample sizes or variances by domain. We apply these rules to our motivating example, the design of a survey of physicians on their experiences with health plans, in which each physician can only be asked about her experience with one plan regardless of her number of affiliations.

This paper on children in Army families is the first to examine objective, non-self-report, measures of all health care utilization inclusive of prescription medications among children experiencing the deployment of a parent. It employs a quasi-experimental, pre–post, non-equivalent group design to compare changes in pediatric health care utilization. Multivariate difference-in-differences regression models isolate the effect of deployment on change in service usage comparing a period prior to deployment to a period starting with the parent’s deployment. The proportion of children using any specialist office visits showed a net increase, while the proportion with any generalist office visits showed a net decline. Post-hoc analysis revealed that these pediatric specialist visits were predominantly, not exclusively, for psychiatric-type services. There also was, in users of antidepressants prescriptions, a 28 % relative increase in children under age 12 and 18 % relative increase in children age 12 years and older. Policy and procedures to support the increased care coordination required of both primary care providers and parents of children who make use of psychiatric specialty services is important, especially since pediatric providers are often in the civilian, and not military, sector.

This study used the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel to determine whether traumatic brain injury (TBI) is associated with past year drinking-related consequences. The study sample included currently drinking personnel who had a combat deployment in the past year and were home for ≥6 months (N = 3,350). Negative binomial regression models were used to assess the incidence rate ratios of consequences, by TBI-level. Experiencing a TBI with a loss of consciousness for more than 20 minutes was significantly associated with consequences independent of demographics, combat exposure, posttraumatic stress disorder, and binge drinking. The study's limitations are noted.

article i nfo Although military men have heavier drinking patterns, military women experience equal or higher rates of dependence symptoms and similar rates of alcohol-related problems as men at lower levels of consumption. Thus, gender may be important for understanding substance use treatment (SUT) utilization before deployment. Military health system data were analyzed to examine gender differences in both substance use diagnosis (SUDX) and SUT in 152,447 Army service members returning from deployments in FY2010. Propensity score analysis of probability of SUDX indicated that women had lower odds (AOR: 0.91, 95% CI: 0.86-0.96) of military lifetime SUDX. After adjusting for lifetime SUDX using propensity score analysis, multivariate regression found women had substantially lower odds (AOR: 0.61; 95% CI: 0.54-0.70) of using SUT the year prior to deployment. Findings suggest gender disparities in military-provided SUT and a need to consider whether military substance use assessment protocols are sensitive to gender differences.

To determine whether combat-acquired traumatic brain injury (TBI) is associated with postdeployment frequent binge drinking among a random sample of active duty military personnel.Active duty military personnel who returned home within the past year from deployment to a combat theater of operations and completed a survey health assessment (N = 7155).Cross-sectional observational study with multivariate analysis of responses to the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, an anonymous, random, population-based assessment of the armed forces.Frequent binge drinking: 5 or more drinks on the same occasion, at least once per week, in the past 30 days. TBI-AC: self-reported altered consciousness only; loss of consciousness (LOC) of less than 1 minute (TBI-LOC1); and LOC of 1 minute or greater (TBI-LOC 1+) after combat injury event exposure.Of active duty military personnel who had a past year combat deployment, 25.6% were frequent binge drinkers and 13.9% reported experiencing a TBI on the deployment, primarily TBI-AC (7.5%). In regression models adjusting for demographics and positive screen for posttraumatic stress disorder, active duty military personnel with TBI had increased odds of frequent binge drinking compared with those with no injury exposure or without TBI: TBI-AC (adjusted odds ratio, 1.48; 95% confidence interval, 1.18-1.84); TBI-LOC 1+ (adjusted odds ratio, 1.67; 95% confidence interval, 1.00-2.79).Traumatic brain injury was significantly associated with past month frequent binge drinking after controlling for posttraumatic stress disorder, combat exposure, and other covariates.

Objectives. Our objective was to analyze the association between deployment characteristics and diagnostic rates for major depression and substance use disorder among active duty personnel. Methods. Using active duty personnel serving between 2001 and 2006 (n = 678 382) and deployment information from the Contingent Tracking System, we identified individuals diagnosed with substance use disorders and major depression from TRICARE health records. We performed logistic regression analysis to assess the effect of deployment location and length on these diagnostic rates. Results. Increased odds of diagnosis with both conditions were associated with deployment to Iraq or Afghanistan compared with nondeployed personnel and with Army and Marine Corps personnel compared with Navy and Air Force personnel. Increases in the likelihood of either diagnosis with deployment length were only observed among Army personnel. Conclusions. There were increased substance use disorders and major depression across services associated with combat conditions. It would be important to assess whether the public health system has adequate resources to handle the increasing need of mental health services in this population.

The Department of Defense (DoD) Military Health System (MHS) embodies decades of health care practice that has evolved in scope and complexity to meet the demands for quality care to which its beneficiaries are entitled. War, Base Realignment and Closure (BRAC), and other dynamic forces require the ongoing review and revision of health care policy and practice in military hospitals as well as the expanded network of civilian providers who care for our nation's soldiers, sailors, airmen, and marines and their families. The result has been an incrementally constructed quality assurance (QA) program with emphasis on organizational structures, programs, and systems, and the use of robust data sources and standard measures to analyze and improve processes, manage disease, assess patient perceptions of care, and ensure that a uniform health care benefit and high quality health care is accessible to all MHS beneficiaries.

Objective To assess racial and ethnic differences in asthma prevalence, treatment patterns, and outcomes among a diverse population of children with equal access to health care. Design Retrospective cohort analysis. Setting The Military Health System. Participants A total of 822 900 children aged 2 through 17 years continuously enrolled throughout 2007 in TRICARE Prime, a health maintenance organization–type benefit provided by the Department of Defense. Main Outcome Measures Prevalence of diagnosed asthma, potentially avoidable asthma hospitalizations, asthma-related emergency department visits, visits to asthma specialists, and use of asthma medications among children aged 2 to 4, 5 to 10, and 11 to 17 years. Results Black and Hispanic children in all age groups were significantly more likely to have an asthma diagnosis than white children (ranging from odds ratio [OR] = 1.16; 95% confidence interval [CI], 1.09-1.24; to OR = 2.00; 95% CI, 1.93-2.07). Black children in all age groups and Hispanic children aged 5 to 10 years were significantly more likely to have any potentially avoidable asthma hospitalizations and asthma-related emergency department visits (ranging from OR = 1.24; 95% CI, 1.11-1.37; to OR = 1.99; 95% CI, 1.37-2.88) and were significantly less likely to visit a specialist (ranging from OR = 0.71; 95% CI, 0.61-0.82; to OR = 0.88; 95% CI, 0.79-0.98) compared with white children. Black children in all age categories were significantly more likely to have filled any prescriptions for inhaled corticosteroids compared with white children (ranging from OR = 1.11; 95% CI, 1.02-1.21; to OR = 1.11; 95% CI, 1.04-1.19). Conclusions Despite universal health insurance coverage, we found evidence of racial and ethnic differences in asthma prevalence, treatment, and outcomes. Published online June 7, 2010 (doi:10.1001/archpediatrics.2010.100).

We compared chronic care utilization in four major health systems in the U.S.: the military health system (TRICARE), the Department of Veterans Affairs (VA), Medicaid, and employer-sponsored commercial plans. Prevalence rates and key performance indicators were constructed from administrative data in federal fiscal year 2003 for eight chronic conditions: hypertension, major depression, diabetes, tobacco dependence, ischemic heart disease, severe mental illness, persistent asthma, and stroke. Continuously enrolled beneficiaries under 65 years old were studied: TRICARE (N = 2,963,987), VA (N = 2,114,739), Medicaid enrollees in five states (N = 5,554,974), and commercial insurance (N = 5,212,833). Condition-specific adjusted prevalence rates and measures were compared using the standardized rate ratio. For the majority of the conditions, the estimated prevalence rates were highest in the VA and Medicaid populations. Prevalence rates were generally lower in TRICARE and commercial plans. Medicaid beneficiaries had the highest hospitalization rates in four of the six conditions where hospitalization rates were measured. These results provide empirical evidence of differences in chronically ill patient populations in several of the major U.S. health insurance systems.

This study estimates the effect of deployment location and length on the risk of developing PTSD, relative to what it would be from the normal military operations. We use a random sample of activity-duty enlisted personnel serving between 2001 and 2006. We identify PTSD cases from TRICARE medical records and link deployment information from Contingent Tracking System. Comparing to those in other duties around the world, deployment to Iraq/Afghanistan increases the odds of developing PTSD substantially, with the largest effect observed for the Navy (OR=9.06, p

NBER WORKING PAPER SERIESTHE EFFECT OF OEF/OIF DEPLOYMENT INTENSITY ON THE RATE OF POSTTRAUMATICSTRESS DISORDER AMONG ACTIVE DUTY POPULATIONYu-Chu ShenJeremy ArkesBoon Wah KwanLai Yee TanThomas V. WilliamsWorking Paper 15203http://www.nber.org/papers/w15203NATIONAL BUREAU OF ECONOMIC RESEARCH1050 Massachusetts AvenueCambridge, MA 02138August 2009Shen and Arkes thank GSBPP DFR program and N1 MPT&E for financial support. From the Centerfor Healthcare Management Studies, Office of the Assistant Secretary of Defense, Health Affairs (OASD(HA)), TRICARE Management Activity (TMA), Falls Church, VA. We thank Dennis Mar, WendyFunk and the staff at DMDC and TMA for assisting with data extraction. The opinions or assertionsherein are those of the authors and do not necessarily reflect the view of the United States Departmentof Defense and any of the affiliated institutions. This work received IRB approvals from NPS, DMDC,TMA, and the Office of Navy Medicine. The views expressed herein are those of the author(s) anddo not necessarily reflect the views of the National Bureau of Economic Research.NBER working papers are circulated for discussion and comment purposes. They have not been peer-reviewed or been subject to the review by the NBER Board of Directors that accompanies officialNBER publications.© 2009 by Yu-Chu Shen, Jeremy Arkes, Boon Wah Kwan, Lai Yee Tan, and Thomas V. Williams.All rights reserved. Short sections of text, not to exceed two paragraphs, may be quoted without explicitpermission provided that full credit, including © notice, is given to the source.

Objectives Timely preventive healthcare services are important to troop readiness and the health of Military Health System (MHS) beneficiaries. Prior studies have reported on use of preventive care among select MHS subgroups, but broader performance is undocumented. This study addresses that gap by comparing TRICARE Prime beneficiaries to select U.S. populations. Methods Rates of prenatal care in the first trimester, flu shots, and screening for breast cancer, cervical cancer, cholesterol, and blood pressure were estimated from the 2004 Health Care Survey of Department of Defense (DoD) Beneficiaries. Rates for U.S. populations were estimated from several national health surveys. Healthy People 2010 goals provided a comparison benchmark. Results Utilization rates of TRICARE Prime enrollees significantly exceeded the U.S. population for all services examined and exceeded the insured U.S. population for flu shots, prenatal care, and screening for breast cancer and cervical cancer. Two Healthy People 2010 goals were met but three were not. Conclusions TRICARE Prime enrollees had similar rates of six clinical preventive care services as insured U.S. populations in 2004, but failed to meet several Healthy People 2010 guidelines. Increased emphasis on these services will be required in order to meet such objectives and reduce long-term health and financial pressures on the MHS.

We employ the Schwartz and Smith [Schwartz, E., and J. Smith, 2000, Short-term variations and long-term dynamics in commodity prices, Management Science 46, 893–911.] model to explore the dynamics of the UK gasmarkets. We discuss in detail the short-termand long-termmarket prices of risk borne by the market players and how deviations from expected cyclical storage affect the short-term market price of risk. Finally, we illustrate an application of the model by pricing interruptible supply contracts that are currently traded in the UK Publicado

This study examined the extent to which high levels of occupational and family stress were associated with mental health problems and productivity loss among active duty military personnel. We analyzed data from the 2002 Department of Defense Survey of Health-Related Behaviors among Military Personnel, which provided extensive population-based information on 12,756 active duty personnel in all branches of the military worldwide. Military personnel reported higher levels of stress at work than in their family life. The personnel reporting the highest levels of occupational stress were those 25 or younger, those who were married with spouses not present, and women. Personnel with high levels of stress had significantly higher rates of mental health problems and productivity loss than those with less stress. We recommend that prevention and intervention efforts geared toward personnel reporting the highest levels of stress be given priority for resources in this population.