Developing and implementing a process improvement intervention to expand evidence-based psychotherapy in the Department of Defense.

Navy Commander helps military patients near and far

In 2017, the TriService Nursing Research Program completed a strategic planning session, which identified key barriers to implementing evidence-based practice (EBP) within the U.S. Military Health System (MHS) including a focus on readiness training and deployments, frequent staff moves for military members, and relatively junior nurses in clinical roles. To facilitate EBP at individual military treatment facilities (MTFs), an EPB Facilitator role was developed using an evidence-based model and based on validated EBP competencies. This new role was implemented at four MTFs in 2018: Naval Medical Center Portsmouth, 59th Medical Wing at Joint Base San Antonio Lackland, Naval Medical Center San Diego, and David Grant USAF Medical Center at Travis Air Force Base. This case series provides a description of the initial implementation of this role. Common enablers and challenges were identified from the experiences at all four sites. These included the importance of incorporating efforts into existing organizational efforts and infrastructure; the value of nurse leaders inviting EBP facilitators to participate and engage in scheduled meetings and committees; the significance of engaging with existing quality, process improvement, and training initiatives; and the benefit of collaborating with advanced practice nurses within the organization. The common challenges for all EBP facilitators were the frequent staff turnover at all levels and a lack of standardization to review and approve EBP initiatives, which makes it difficult to navigate the complete process of project implementation and collaboration across sites. Another challenge has been the difficulty to measure the impact of this role at the MTF and MHS levels. As EBP efforts continue and the program matures, it is anticipated that the outcomes from the individually completed projects, to include decreases in safety events, fiscal savings, and other improvements in organizational metrics, can be compiled to demonstrate the collective impact of these roles within the MHS.

Improving Care During Peacetime, War, and Disasters: A Call for Agile Military Civilian Strategic Alliances.

Military Graduate Medical Education (GME) has long been considered a cornerstone of the Military Health System (MHS) and comprises 3% of the nation’s GME positions. In these times of fiscal uncertainty, the $9.5 billion the federal government annually contributes to teaching hospitals through Medicare is under significant scrutiny. With MHS consuming 10% of the Department of Defense (DoD) budget, the cost-benefit of military GME is likely to be questioned yet again. As early as 2006, an Office of the Secretary of Defense, Health Affair’s sponsored report stated we must be willing to “admit the rhetoric of needing GME to maintain the force structure as it relates to quality, recruitment, and cost effectiveness may not be true.” This report concluded, “A critical re-look at DoD-sponsored GME is needed today. The King may not be naked—but his clothing is tattered.” As I pondered whether the allure of military GME was more rhetoric than reality, a question crossed my mind. “Why do a number of cost-conscience, quality health care delivery institutions such as Kaiser Permanente (KP), Geisinger Health System, and Intermountain Healthcare engage and value GME?” The President of KP Southern California, after noting a lack of financial incentive, stated their health care system should become even more involved in GME. Are there insights into the value of GME the MHS might gain from health care systems like KP? Further, any significant changes in military GME should be considered in the context of growing challenges in meeting the health care needs of the country, the shifting accreditation emphasis on patient safety and quality improvement, and the impact of residency training on future practice. Senior leaders at KP reported several reasons for being engaged in GME for over 60 years: grounding residents in their culture; growing future leaders; positive impact on faculty recruitment, quality, satisfaction, and retention; workforce contribution; research; and enhancing the image of the organization. They assert “grounding of trainees in the fundamentals of Permanente Medicine virtually ensures a cultural fit.” Given the unique nature of military medicine, the value of MHS acculturation during training should not be underestimated. A military physician’s career may result in movement among five different cultures: academic, clinical, research, administrative, and military-unique operations. During the last decade of conflict, military GME teaching faculty, nurses, support staff, and patients have lived the “raison d’etre,” as the operational culture has been described. They bring this back to the classroom, the health care team, and the bedside. Like KP, we breed our future health care leaders in this training culture. Our military treatment facilities (MTFs) contain key ingredients described by a Nobel Laureate, Robert Fogel, found in a flourishing culture: a common sense of community, purpose, general discipline, and a strong work ethic. Given challenges with military life (deployments, moves, lower career pay), incentives are needed to retain top physicians, who, in turn, recruit our future DoD physicians. Yet recruitment, satisfaction, and retention of highly qualified providers remain vexing problems for the MHS, with 15% to 30% annual turnover. Turnover is expensive, costing one college of medicine with an annual 6.7% turnover an estimated 45 million dollars over 5 years. A significant proportion of the cost was due to orienting to the new practice setting. Perhaps this further explains why KP is willing to finance GME. KP hires 30% of their former residents, who make up 15% of their faculty workforce. The Department of Veterans Affairs (VA), with an annual turnover of 9%, found residents are twice as likely to consider a VA career after their rotations. Office of the Dean, Graduate Medical Education, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234-4504. This article was presented at the Department of Pediatrics Grand Rounds, Uniformed Services University, Bethesda, MD, April 11, 2013. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Air Force, Department of the Army, Department of Defense, or the U.S. Government. This work was prepared as part of their official duties and, as such, there is no copyright to be transferred. doi: 10.7205/MILMED-D-13-00283

This study estimated the direct medical and indirect costs associated with coronavirus disease 2019 (COVID-19) diagnoses among U.S. active duty (AD) Army service members (SMs). These cost estimates provide the U.S. Military with a better understanding of the financial burden of COVID-19 and provide a foundation for cost-effectiveness estimates. The study was approved as Public Health Practice (#17-605) by the U.S. Army Public Health Center, Public Health Review Board. U.S. AD Army SMs with COVID-19 were identified using an Army COVID-19 testing and surveillance database. Encounters for these SMs were captured from medical record where International Classification of Disease Tenth Revision, Clinical Modification code U07.1 was in the first or second diagnostic position. Analyses were conducted on SMs with COVID-19 who either had no healthcare encounters in the Military Health System (MHS); at least one MHS COVID-19 inpatient hospitalization; or at least one MHS outpatient COVID-19 encounter. Coronavirus disease 2019 (COVID-19) costs captured from the encounters were used to develop direct medical cost estimates. Literature on COVID-19 recovery post-hospitalization, along with the number of COVID-19 hospitalizations and outpatient visits from encounters were used to describe the intensity of COVID-19 care. Estimates of the indirect cost of lost duty were based on SMs salary information, along with recovery time, bed days, or outpatient visit time. The indirect cost of limited duty was estimated using the time associated with the Department of Defense (DoD) COVID-19 pandemic mitigation strategies in place when these SMs were identified as positive for COVID-19. Coronavirus disease 2019 (COVID-19) cost estimates were developed for the Army using data from 19,086 SMs identified as positive for COVID-19 between June 1, 2020, and December 31, 2020. Direct medical costs, or the amount paid by the DoD to facilities for COVID-19 care, averaged $606 per SM with an encounter. Indirect costs for lost duty or the cost for recovery and the time taken to seek care for COVID-19 averaged $319 per SM, while indirect costs for limited duty or isolation associated with COVID-19 averaged $4,111 per SM or $411 per day. Service members (SMs) with an inpatient hospitalization averaged 4.8 bed days (range 1-43) and 266 recovery hours while SMs who sought outpatient care for COVID-19 averaged two outpatient visits (range 1-60 visits). The direct medical costs of a COVID-19 encounter in the MHS ($606) are a small portion of the costs for a SM with COVID-19. Indirect costs of lost and limited duty associated with COVID-19 averaged seven times higher ($4,331) and accounted for the vast majority of costs. Recognition of these costs is important especially given that soldiers in the hospital or in quarters being quarantined are complete losses of manpower to the Army. While the COVID-19 pandemic is ongoing and prevention, treatment, and mitigation efforts continue to evolve, having reliable estimates of direct medical and indirect costs from this study allows the U.S. Army and MHS to better account for the cost of this pandemic for its population.

Back to table of contents Previous article Next article Professional NewsFull AccessMajor Study Will Assess 'What Works' in PTSD CareAaron LevinAaron LevinPublished Online:1 Apr 2011https://doi.org/10.1176/pn.46.7.psychnews_46_7_4_1AbstractThe Department of Defense and the Department of Veterans Affairs have received enormous funding from Congress for treating PTSD, but we can't view that as a bottomless pit," Navy Capt. Paul Hammer, M.C., said at the first meeting of an Institute of Medicine (IOM) panel that will study the current status of research and treatment of posttraumatic stress disorder (PTSD). "We have to learn to treat PTSD at a reasonable cost," said Hammer, an APA member and the new director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Doing that requires knowing more about the disorder, its causes, diagnosis, and treatment, so the Department of Defense (DoD) requested the IOM study. The panel is chaired by Sandro Galea, M.D., Dr.P.H., a professor and chair of the Department of Epidemiology in the Mailman School of Public Health at Columbia University. The request came three years after another report from the IOM noting that "significant gaps" existed in the evidence underlying nearly all treatments for PTSD (Psychiatric News, December 7, 2007). The earlier report said that only therapies that included some element of exposure to reminders of trauma—like prolonged exposure therapy, cognitive-behavioral therapy, or cognitive-processing therapy—were backed by sufficient evidence from clinical trials. "The 2007 PTSD report was simply an evaluation of the evidence on best practices for PTSD," said Galea. "Our mandate with this study is to understand what the best approach to screening, prevention, treatment, and rehabilitation for PTSD is and what DoD and the Department of Veterans Affairs [VA] should be doing about it." The panel will spend two years gathering information from the two federal departments "on programs and methods available for the prevention, screening, diagnosis, treatment, and rehabilitation of posttraumatic stress disorder," as well as study clinical trials of innovative treatments and services. The panel will then take another two years to evaluate the rates of success of each modality. The study could clarify how well current PTSD programs are working and identify gaps in assessment and treatment, said Hammer during the panel's initial meeting in late February. About 2.4 percent of the 2.2 million deployed service members have been diagnosed with PTSD, but depending on survey methodology, 10 percent to 17 percent of service members report some symptoms of PTSD, he noted. Several areas require special attention in any study of PTSD in military populations, Hammer pointed out.For example, "patterns of comorbidities are different in military populations, compared to the civilian sector," he said. Mild traumatic brain injury, pain, and substance abuse are common. In addition, combat troops less often report Category A ("horror") PTSD symptoms, because their military training and experience prepares them for battle. But they also have less access to protective factors due to their frequent re-exposure and the "tough-it-out" military culture, he said. National Guard and Reserve personnel are at even greater risk of PTSD and have less access to therapists skilled in PTSD care for military populations because they are dispersed geographically after they return from war zones. The armed forces have used several strategies to protect troops. Education and training begin at the start of military service. Increased screening and surveillance, interventions to manage combat stress in the field, and a full spectrum of available treatments in war zones and at home also serve as factors that may mitigate the likelihood or severity of PTSD. The Military Health System has increased behavioral health staffing from about 4,000 in 2007 to about 6,500 now, so fewer referrals for care go unfulfilled. Spending on PTSD care for the current cohort of veterans is likely to be high, and the true costs of treating them needed to be made clear, said Hammer. But more work needs to be done first. "Data are problematic on the effectiveness of current therapies," said Hammer. "We don't know what type of therapy is used or whether the therapist has made individual modifications. We don't have the ability to track measures over time." The executive director of the VA's National Center for PTSD (NCPTSD), Matthew Friedman, M.D., Ph.D., stressed that more should be done to monitor outcomes in clinical practice, expand the use of evidence-based therapies and clinical practice guidelines, and increase quality improvement and program evaluation efforts. The National Center for PTSD is a hub for research into the neuroscience of PTSD and its treatment, along with ways to move that research into the clinic. Basic research there now addresses mechanisms underlying the development of PTSD, as well as resilience, treatment effectiveness, and treatment resistance, Friedman told the IOM panel. The NCPTSD also provides PTSD-related assessment tools, training, treatment guides, and consultation services within the VA, he said. In addition, it provides information on PTSD and its treatment for outside clinicians and for the public via its Web site. The IOM study, when completed, will help guide future DoD and VA policies for screening, diagnosing, and treating service members and veterans. That can't come too soon, said Hammer. "We need to get it right and target well for what works," said Hammer.Information on the Institute of Medicine's "Assessment of Ongoing Efforts in the Treatment of PTSD" is posted at <www.iom.edu/Activities/Veterans/PTSDTreatment.aspx>. The Web site for the National Center for PTSD is <www.ptsd.va.gov>. ISSUES New Archived

Studies of the small numbers of younger cases in older existing cohorts will not allow us to clearly understand the factors associated with the rising rates of early onset cancers in the last 25 years. While clearly genetic susceptibility plays a role in the etiology of cancer, population genetics are not changing as rapidly as the rates of early onset cancers. We must make use of existing prospective data from young individuals, in the birth cohorts for whom cancer rates are increasing, to investigate contemporary exposures. Cancer rates have increased in the population of more than 1.3 million individuals in the U.S. military in parallel to the general population despite the required military health and fitness standards. This population and their linked data available in the Military Health System provides a valuable resource to investigate environmental exposures alone or in combination with genetic susceptibility and the associations with early onset cancers. The average age of this racially and ethically diverse population is ∼29 years old with those &amp;gt;30 years old increasing in recent decades. Although the cohort is predominantly male, females still make up about 18% of the active-duty force. For those on active duty, information collected during their service from the military medical, occupational, and pharmaceutical databases with analyses of serial serum samples, obtained approximately every two years since the late 1980’s, can be analyzed to identify factors that impact the risk of early onset cancers. Even if all information of interest may not be available and the number and volume of samples for each subject is limited, researchers can still glean a great deal from studies of this population. Considering the methodological factors of both calendar time in measured exposures and timing with respect to diagnosis allows for the potential identification of the relevant windows of susceptibility to specific exposures. The most appropriate study design and methods for implementation as well as the limitations to consider will be presented. Ongoing nested-case-control studies focusing on testicular, breast, colorectal, thyroid, and pancreatic cancers use these resources to study the environmental determinants of early onset cancers in this population. Access to these resources is currently available through collaboration with Department of Defense researchers. Plans are developing for wider access with future linkage with the national virtual pooled cancer registry that will enable identification of those diagnosed after leaving military service. The views expressed are those of the author and do not necessarily reflect the official views of the Uniformed Services University of the Health Sciences or the Department of Defense. Citation Format: Celia Byrne. Studying early onset cancer: benefits and limitations of studies within the Military Health System [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: The Rise in Early-Onset Cancers—Knowledge Gaps and Research Opportunities; 2025 Dec 10-13; Montreal, QC, Canada. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(23_Suppl):Abstract nr C023.

It has been demonstrated that there was an increase in later-stage prostate cancer (PCa) at diagnosis after the U.S. Preventive Services Task Force recommended against prostate-specific antigen screening for prostate cancer. However, the cancer characteristics at diagnosis within the equal-access Military Health System (MHS) during the period have not been described. In this study, we compared PCa stage at diagnosis and its trends between the military health care system and the general public and further compared the trends in tumor stage by race. This study was based on nonidentifiable data from the U.S. Department of Defense's Central Cancer Registry (CCR) and the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute. Patients diagnosed between 2004 and 2014 were included. The distributions of PCa stage at diagnosis over time were compared between the 2 populations. Comparisons were further conducted for White and Black patients, respectively. Among the 11,895 patients in the CCR and 544,142 patients in SEER, the majority of patients were diagnosed with stage I or II prostate cancer. However, the CCR had a larger proportion of early-stage tumors (stages I and II combined) with 84.3% vs. 80.0% of SEER patients. The proportion of late-stage tumors (stages III and IV combined) increased over time from 2008 for both populations and the proportion of early-stage tumors decreased for the general population. In terms of temporal distributions by race, the trends were the same between White and Black groups in the general population. In the MHS, the trends in the White patients were similar to those in the general population, but in the Black patients, the percentages of stages I and II at diagnosis continued to increase and those of stages III and IV decreased, differing from those in the general population. The MHS consistently diagnosed PCa at an earlier stage than the U.S. general population across all time periods evaluated in this study. Although similar trends were observed for White patients between both populations, the proportion of stages I and II at diagnosis increased from 2012 among Black patients in the MHS, which stands in sharp contrast to trends in the U.S. general population. Although the differences between the two populations may be associated with various factors, differences in accessibility to care and thus the use of prostate-specific antigen testing might play an important role.

Military Family and Women's Health Nurse Practitioners (NPs) serve vital roles in garrison and operational missions within the Military Health System (MHS). They require specialized education, necessitating military-specific competencies to ensure operational readiness and effective care. This article explores the competencies, which are aligned with the ten domains defined by the American Association of Colleges of Nursing and National Organization of Nurse Practitioner Faculties, through a case study that demonstrates the practical application of these competencies as a novice NP confronts the complex realities of healthcare delivery across the operational and clinical landscapes of the MHS. It highlights the unique skills required for military NP practice, including advanced diagnostics, population health management, and the ability to integrate evidence-based practice in resource-constrained settings. Successful application of these competencies hinges on the NP's knowledge of the MHS structure, military culture, operational roles, and their capacity for effective interprofessional collaboration. This commentary is intended for leaders in military health education, clinical and operational leadership within the MHS, and policy-makers responsible for workforce development. By outlining essential military-specific competencies, this work provides a framework for onboarding other novice healthcare professionals, ultimately strengthening military healthcare delivery and enhancing a Ready Medical Force capable of optimizing a Medically Ready Force.

The role of organisational motivation and coordination in continuous improvement implementations: an empirical research of process improvement project success

Introduction During the COVID-19 pandemic, healthcare systems implemented restrictions on in-person appointments to mitigate viral spread among healthcare workers and patients. This study assesses changes in cervical cancer screening (CCS) rates within the United States Military Health System (MHS) during this period. To date, no such data have been reported on COVID-19's effect on CCS within the MHS. Methods This retrospective cohort study compares CCS rates from the pandemic period of February 1, 2020, to February 28, 2022, to a pre-pandemic cohort spanning January 1, 2013, to January 31, 2020. Screening rates were analyzed using interrupted time series and regression methods. Results Results indicate a statistically significant decline in adequately screened patients, dropping from 77.9% (684,923 of 879,091 eligible patients) in January 2013 to 70.0% (457,109 of 652,507 eligible patients) in February 2021 (p<0.05). A statistically significant drop was also noted when comparing February 2020 (76.5%, 583,941 of 763,692 eligible patients) to February 2021 (70.0%, 457,109 of 652,507 eligible patients; p<0.05) and to February 2022 (72.3%, 496,100 of 686,029 eligible patients; p<0.05). The average pre-pandemic CCS rate of 75.5% significantly differed from the pandemic period's average of 73.3% (p<0.00001), representing 17,452 patients with inadequate screening during the pandemic. Conclusion This study highlights a substantial reduction in CCS within the MHS during the COVID-19 pandemic, aligning with national trends in cancer screening. It underscores the need for sustained healthcare access during crises and emphasizes the importance of planning to uphold essential preventative services. Future research should explore strategies to mitigate pandemic-related disruptions in cancer screening and their long-term implications on public health.

The Veterans Health Administration (VA) provides a case study for linking performance measurement, information technology, and aligned research efforts to facilitate quality improvement in a large, complex health system. Dialogue between clinical researchers and VA leaders occurs through structured activities (e.g., the Quality Enhancement Research Initiative); engagement with formal policymaking bodies (e.g., development of clinical guidelines and performance measures); and informally through local, regional, and national work groups responsible for implementing evidence-based clinical initiatives. Important lessons for knowledge translation from the VA experience include the following: research needs to generate clinical evidence relevant to the needs of patients served by the health system; researchers need to systematically study the process of evidence implementation itself to increase the capability of the health system to improve performance; although print and Web-based dissemination structures are important, direct accessibility of researchers to policymakers and clinical leaders through formal and informal mechanisms is key; and both top-down and bottom-up activities are needed to integrate evidence-based practice across a large health system. As VA care moves from hospital and clinic into community-based settings and faces a new veteran population with different needs and expectations, knowledge-translation activities must develop new forms of evidence and more direct interaction with veterans and their caregivers.

The COVID-19 pandemic prompted sweeping changes to behavioral health care delivery in the Military Health System (MHS), which turned to telehealth to minimize disruptions and ensure continuity of care for service members. Four to seven months into the pandemic, MHS behavioral health staff at ten military treatment facilities shared their experiences using telehealth and their perspectives on its utility, barriers to its wider integration in the MHS, and concerns about its use in the post-pandemic future. Telehealth use was previously low across the MHS, but it increased dramatically with the onset of the pandemic. At the time they were interviewed, nearly all providers who treated service members with posttraumatic stress disorder, depression, or substance use disorders were using audio-only telehealth in some capacity. Although most were not using video telehealth, three-quarters expressed an openness to using it in the future. However, the widespread integration of telehealth in the MHS will need to include efforts to overcome technical and administrative barriers and to address provider concerns about telehealth modalities for behavioral health care delivery-for example, the need for clinical guidance on using telehealth with specific types of patients, and provider and patient orientation on using telehealth technology.

This study examines the economic burden of alcohol misuse to the Department of Defense (DoD) and the benefits of reduced binge drinking among beneficiaries in the DoD's TRICARE Prime plan. Data analyzed include administrative records for approximately 3 million beneficiaries age 18 to 64, DoD's Survey of Health Related Behaviors Among Military Personnel, and the National Survey on Drug Use and Health. Alcohol misuse among Prime beneficiaries cost the DoD an estimated $1.2 billion in 2006--$425 million in higher medical costs and $745 million in reduced readiness and misconduct charges. Potential annual gross benefits to the DoD of reduced binge drinking are simulated for three scenarios: (1) implementing a comprehensive alcohol screening with referral to brief intervention or treatment by primary care ($87 million/$129 million in short/long-term benefits); (2) increasing the price of alcoholic beverages on military installations by 20% ($75 million/$115 million); and (3) implementing a Web-based education program ($81 million/$123 million).

Within the population of military service members and veterans, chronic pain is highly prevalent, often complex, and frequently related to traumatic experiences that are more likely to occur to members of this demographic, such as individuals with traumatic brain injury or limb loss. In September 2017, the National Institutes of Health (NIH), Department of Defense (DOD), and Department of Veterans Affairs (VA) Pain Management Collaboratory (PMC) was formed as a significant and innovative inter-government agency partnership to support a multicomponent research initiative focusing on nonpharmacological approaches for pain management addressing the needs of service members, their dependents, and veterans. A Pain Management Collaboratory Coordinating Center (PMC3) was also established to facilitate collective learning across 11 individually funded pragmatic clinical trials (PCTs) designed to optimize the impact of the PMC as an integrated whole. Although the DOD and VA health care systems are ideal sites for the enactment of PCTs, executing these trials within the local context of DOD military treatment facilities (MTFs) can present unique challenges. The Military Treatment Facility Engagement Committee (MTFEC) was created to support the efforts of the PMC3 in its role as a national resource for development and refinement of innovative tools, best practices, and other resources in the conduct of high impact PCTs. The MTFEC is composed of experts from each service who bring experiences in executing clinical pain management trials that can enhance the planning and execution of the PCTs. It provides expertise and leadership in the execution of research studies at within MTFs and within the DOD health care system, with guidance from PMC3 Directors and in collaboration with NIH, DOD, and VA program and scientific officers. Considering the importance of enacting large-scale, pragmatic studies to implement effective strategies in clinical practice for chronic pain management, the MTFEC has begun to actualize its purpose by identifying potential barriers and challenges to study implementation and exploring how the PMC can support and aid in the execution of PCTs by applying similar approaches to stakeholder and subject matter engagement for their research.