Abstruse

Introduction

More than than twoscore,000 soldiers cannot deploy every yr, which undermines readiness. The medical readiness of soldiers is a disquisitional component of the overall operational readiness of the U.S. Regular army. Acute musculoskeletal injuries (MSIs) are the greatest threat to medical readiness. Medical providers place soldiers on temporary profiles to facilitate treatment and recovery of acute MSIs. Poorly managed temporary profiles negatively affect a soldier's piece of work attendance, resulting in the loss or limitation of over 25 million workdays annually. Upgrading the electronic contour system and implementing the Army Medical Home has led to improvements in managing temporary profiles over the last decade. The Army Medical Home encompasses care delivery platforms, including the Patient-Centered Medical Domicile (PCMH) and Soldier-Centered Medical Dwelling (SCMH). The structure of U.South. Regular army PCMHs and SCMHs differ in means that may affect care processes and patient outcomes. Temporary profile direction is an of import soldier health outcome that has not been studied in relation to the U.S. Army's PCMH and SCMH structures or care processes. Access to care, continuity, and communication are three care processes that take been described as essential factors in reducing lost workdays and functional limitations in workers after an acute injury. Understanding the touch of the medical home on temporary profile days is vital to medical readiness. This written report aimed to (1) compare temporary contour days between the U.S. Army PCMHs and SCMHs and (2) determine the influence of medical abode structures and care processes on temporary profile days among active duty U.S. Ground forces soldiers receiving care for MSIs.

Materials and Methods

This was a retrospective, cantankerous-sectional, and correlational study guided by Donabedian'southward conceptual framework. We used secondary data from the Military Data Repository nerveless in 2018. The sample included 27,214 temporary profile records of active duty U.Southward. Regular army soldiers and 266 U.South. Regular army PCMH and SCMH teams. We evaluated bivariate and multivariate associations between outcomes and predictors using general and generalized linear mixed regression models. The U.South. Ground forces Medical Section Center and School Institutional Review Board approved this study.

Results

Total temporary contour days ranged from 1 to 357, with a hateful of 37 days (95% CI [36.2, 37.0]). There was a pregnant difference in mean temporary profile days between PCMHs (43) and SCMHs (35) (P < 0.001). Soldiers in PCMHs were more likely to have temporary profiles over 90 days (OR = 1.54, 95% CI [1.17, 2.03]). Soldiers in the heavy physical demand category had fewer temporary contour days (P < 0.001) than those in the moderate concrete need category. Age, sex, rank level, physical need category, profile severity, medical home type, the "explain things" communication subscale, and primary care manager continuity were significant predictors of temporary contour days.

Conclusions

Excessive temporary contour days threaten medical readiness and overall soldier wellness. Aspects of the medical home structure and care processes were predictors of temporary profile days for musculoskeletal conditions. This piece of work supports continued efforts to meliorate MSI-related outcomes among soldiers. Knowledge gained from this study can guide futurity research questions and assistance the U.S. Army meliorate meet soldier needs.

INTRODUCTION

More than 40,000 (x%) soldiers are unable to deploy every year due to administrative and medical reasons, 1 which undermines military readiness. Readiness is the ability of the U.South. Army to conduct out a range of military machine operations. It encompasses operational planning, supply, training, and the medical readiness of soldiers. 2 Medical readiness, a soldier's ability to perform combat tasks and deploy to harsh environments, free from any medical limitations, 3 is a disquisitional component of the overall operational readiness and warfighting adequacy of the U.S. Army.

The greatest threat to medical readiness is acute musculoskeletal injuries (MSIs). 4,five These MSIs are caused by military training, gainsay operations, occupational tasks, and other physical activities that significantly strain the musculoskeletal system. 6,7 MSIs among soldiers outcome in over 2 million outpatient medical encounters each yr. eight In 2018, MSIs deemed for over $430 million in direct care costs. 9 Additionally, MSIs event in over 36% of service-connected disabilities, greater than any other body organization. ten

Medical providers place soldiers on temporary profiles to facilitate treatment and recovery of acute MSIs if the soldier is expected to recover within a reasonable amount of time. 11 A medical provider documents activity that the soldier can and cannot perform because of the injury and how the injury might affect the soldier'south power to do their chore, have a concrete fitness examination, or deploy. Temporary profiles are documented in an automated spider web-based organisation known as "e-Profile." 12 The due east-Profile system serves as a centralized location for documentation, reporting, and 3-manner communication between soldiers, medical providers, and unit leaders regarding soldiers' functional capabilities and duty limitations. 12

The number of days a soldier is on a temporary profile afterward an acute MSI varies but typically ranges from 7 to xc days. six,13 Medical providers may extend a temporary contour up to 12 months. If the status cannot be stabilized or is stabilized within this time even so impacts the soldier'south ability to perform basic soldiering skills, task-specific duties, and at to the lowest degree 1 aerobic physical fettle test event, the soldier may be evaluated for medical retentivity. 11 A medical retention evaluation determines if a soldier can transition to a permanent profile or enter the appropriate disability evaluation system for job reclassification or medical discharge from the U.Due south. Army. 11

Poorly managed temporary profiles negatively bear on a soldier's piece of work attendance resulting in the loss or limitation of over 25 meg workdays each yr. half dozen Implementing and upgrading the e-Profile arrangement fourteen and revisions to the policies that govern medical readiness monitoring has led to improvements in managing temporary profiles over the final x years. In improver, changes within the U.Southward. Army master intendance setting where temporary profiles are typically documented may have also influenced temporary contour management.

The implementation of the Army Medical Home, beginning in 2009, has led to various improvements in care commitment and patient outcomes among military machine beneficiaries. 15 The Army Medical Home is a comprehensive intendance delivery system encompassing nationally recognized principles of patient-centered intendance, including enhanced access and communication, team-based patient direction, master intendance director (PCM) continuity, care coordination, and a system-based approach to patient safety and quality improvement. xvi The Army Medical Dwelling house includes diverse care commitment platforms, including the Patient-Centered Medical Dwelling house (PCMH) and Soldier-Centered Medical Domicile (SCMH). The PCMHs within the U.South. Army provide main care for soldiers, family unit members, and retirees. The U.S. Army refers to the SCMH as the "soldier version" of the PCMH. 3 The SCMHs provide primary care services to agile duty soldiers assigned to battalions within large operational Ground forces units known every bit brigade gainsay teams. 3

The structure of U.S. Army PCMHs and SCMHs, east.g., integrated staffing model, leadership construction, and the mode soldiers are assigned to medical domicile teams based on their assigned operational unit of measurement, 3 differ in ways that may bear upon the performance of care processes and patient outcomes. 17 Temporary profile management is an important soldier health effect that has not been studied in relation to the U.S. Army's PCMH and SCMH structures or care processes. Access to care, PCM continuity, and patient-centered communication, in item, are iii care processes that take been described as essential factors in reducing lost workdays and functional limitations in workers later on an acute injury. 18–twenty Understanding the bear on of the medical home on temporary profile days is vital to medical readiness. This study aimed to (i) compare temporary profile days between the U.Due south. Regular army PCMHs and SCMHs and (2) determine the influence of medical domicile structures and care processes on temporary contour days among active duty U.S. Army soldiers receiving care for MSIs.

Conceptual Framework

Donabedian's 21 conceptual framework guided this study. Co-ordinate to Donabedian, the quality of care and wellness services can be examined within the context of structure, process, and outcome. 21 This framework suggests that each of these 3 components affects the proceeding 1 in a linear and interdependent way. An organization's construction includes the setting and methods that support clinical services, east.k., the system, material and human being resources, and patient characteristics. Processes inside a healthcare organization include the technical and interpersonal activities within and between the clinical staff and patients. The outcomes are the health and welfare consequences, desirable or undesirable, of individual patients or a population. 21

In this study, the structures are represented by medical home and soldier characteristics. The processes include access to care (i.e., timely utilize of healthcare services), PCM continuity (i.east., a continuous relationship betwixt a patient and their PCM), and patient-centered advice (i.e., an interpersonal procedure that includes clear, respectful, and considerate dialogue between the patient and the provider). The outcome of interest is full temporary profile days (see Fig. 1).

Figure i.

Donabedian's Conceptual Framework and the associations examined in this study.

Donabedian's Conceptual Framework and the associations examined in this study.

Effigy one.

Donabedian's Conceptual Framework and the associations examined in this study.

Donabedian'south Conceptual Framework and the associations examined in this study.

METHODS

Design, Setting, and Sample

This retrospective, cross-sectional, and correlational study used a subset of data from the War machine Information Repository. The sample included 27,214 temporary profile records of active duty U.S. Army soldiers and 266 U.South. Regular army PCMH and SCMH teams. All medical homes inside the U.S. Army are accredited by the Joint Commission Medical Dwelling Certification Program.

Inclusion and Exclusion Criteria

We included temporary profile records written for soldiers in the agile component of the U.S. Army, between January 1, 2018 and December 31, 2018, for any musculoskeletal status, past providers who also had a returned patient experience survey during this period. We excluded medical home teams with less than five% active duty soldiers enrolled and pediatric service designators. Customs-Based Medical Homes and specialty care cost centers such as sports medicine, rehabilitation and transition care, immunizations, acute intendance, and student-only clinics were likewise excluded. Fort Belvoir Army Medical Eye and Walter Reed Military machine Medical Middle clinics were excluded because they were realigned under the Defense Health Bureau before 2018 and may have been operating under policies that differ from U.S. Army clinics.

Protection of Human Subjects

The U.S. Army Medical Department Center and School Institutional Review Lath approved this study. The data were extracted per approved Defense Wellness Agency and U.Southward. Ground forces Office of the Surgeon General information-sharing agreements.

Measures

Instrument

Soldiers' perception of admission to care, continuity, and communication was assessed using secondary data from the Joint Outpatient Experience Survey-Consumer Assessment of Healthcare Providers and Systems Clinician and Group (JOES-C) instrument. The JOES-C is a comprehensive self-study, outpatient feel calibration that encompasses a total of 43 questions. Thirty questions were taken from the Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CAHPS-CG) Version iii.0 survey tool. 22 Thirteen questions were created by the Department of Defense. 23

Psychometric analyses of the CAHPS-CG provider communication composite measure used in this study indicate that the measure is reliable and valid. 24–26 The question used to assess the soldier's perception of access to care is a Section of Defense custom question. We created the PCM continuity composite using questions categorized as JOES-C single-item demographic questions.

Variables

The following is a clarification of the consequence and predictor variables in this study.

Total temporary profile days.

Total temporary profile days were the cumulative number of days a soldier was prescribed physical limitations to recover from any MSI between January i, 2018 and December 31, 2018. We subtracted the documented end date of the profile from the start appointment to get the duration for each profile. We then added contour durations for each soldier to get the total number of profile days for calendar year 2018.

Total temporary profiles over 90 days.

Nosotros created a binary variable for total temporary profile days; ≥ 90 days = 1 and < 90 days = 0. Temporary profiles can be written for up to ninety days. At xc days, a temporary profile requires reassessment by a provider to be extended. 12

Medical home type.

We created a binary variable for medical abode type: PCMHs and SCMHs were designated based on their unique Medical Expense and Performance Reporting System code and standardized Ground forces Medical Home naming convention.

Soldier characteristics.

Soldier characteristics included demographics such as age, sex, race, and rank level. Age is a continuous variable, defined as age at the time the temporary profile was prescribed. Sex activity is a categorical variable described by the gender marker documented in the soldier'south medical record (i.e., male or female). Race was based on demographic data reported in the soldier's medical record (i.e., White, Black, Asian or Pacific Islander, Native American or Alaska Native, or Other). Rank level was divided into six categories based on the soldier'due south pay grade (i.due east., Junior Enlisted (E1–E5), Senior Enlisted (E6–E9), Junior Officeholder (O1–O3), Senior Officer (O4–O9), Inferior Warrant (WO1–CW2), and Senior Warrant (CW3–CW5). Concrete demand categories (moderate, meaning, and heavy) are defined past a soldier's chief military occupation (eastward.g., infantry, mechanic, signal), area of concentration, and rank. 27 The profiling provider reports profile severity (i.due east., mild, moderate, or severe) based on the soldier's injury and functional capacity. 12

Admission to intendance.

We examined access to care using the following three variables:

Third Next Available 24-Hour Appointment.

This measure is the number of days from the date a patient requests an appointment for an acute condition to the tertiary open up appointment within an unabridged dispensary's schedule for all providers.

Third Adjacent Available Time to come Appointment.

This measure is the number of days from the appointment a patient requests an appointment for follow-upward or routine intendance to the third open appointment within an entire clinic'south schedule for all providers.

Soldiers' Perception of Access to Care.

This JOES-C question asks survey respondents, "How much do you agree or disagree with the following statement: In general, I am able to see my provider when needed." The respondent selects ane choice from a five-point Likert scale, ane= "strongly disagree," 2= "somewhat disagree," 3= "neither agree nor disagree," 4= "somewhat agree," and 5= "strongly agree."

Continuity.

We examined continuity using the following iii variables:

Master Care Manager Continuity.

This measure was calculated by the ratio of "kept" 24 60 minutes and future master care appointments, where active duty soldiers saw their assigned PCM, divided past the full number of 24 hour and time to come primary care appointments for active duty soldiers in that medical home team.

Medical Home Team Continuity.

This measure out was calculated by the ratio of kept 24 hour and future main care appointments, where active duty soldiers saw their assigned PCM or another provider within their assigned medical home team, divided past the full number of 24 hr and hereafter master intendance appointments for agile duty soldiers in that medical home team.

Primary Care Manager Continuity Blended Score.

We created the PCM continuity composite score by averaging the weighed sum of responses to the following four JOES-C questions: (i) "Our records testify that you got intendance from the provider named below in the last 6 months;" (ii) "Is this the provider you lot usually run across if you lot need a check-upward, want communication about a health problem, or get ill or injure;" (iii) "How long have you been going to this provider;" and (iv) "In the final six months, how many times did you visit this provider to get care for yourself?" The response options for the first two questions were "yes" or "no." The response options for the latter two questions were a Likert scale (eastward.thou., 1 ="less than six months," 2 = "at least 6 months merely less than 1 year, etc.). A college composite score corresponded to a meliorate perception of continuity.

Communication
Provider Advice Subscale Scores.

The communication subscale scores are calculated by the percentage of "always" responses to the following JOES-C questions: In the concluding 6 months, how often did this provider (i) "explain things in a manner that was easy to understand;" (2) "heed carefully to you lot;" (iii) "prove respect for what you had to say;" and (4) "spend plenty fourth dimension with y'all?" The response options are a iv-indicate Likert scale i= "never," 2= "sometimes," 3= "usually," and 4= "e'er."

Data Analysis

The data were examined for inclusion and exclusion criteria, outliers, and missingness. We analyzed outliers using statistical comparisons. The full data maximum likelihood approach was used to handle missing data. Continuous variables were summarized as mean, standard difference, and 95% conviction interval (95% CI). Categorical variables were summarized using odds ratios and 95% CI. Our analysis included soldier-level outcomes (i.east., total temporary profile days and temporary profiles over ninety days) and predictor variables (i.due east., soldier characteristics), besides as predictor variables aggregated to the medical home team level (i.e., medical home type, access, continuity, and communication) for agile duty soldiers only (meet Supplemental A). Considering how medical dwelling teams are aligned under larger military treatment facilities, we deemed the information nested (i.e., soldiers and care processes may share similarities) by medical domicile squad, health clinic, and medical center (come across Supplemental B). We evaluated bivariate and multivariate associations betwixt outcomes and predictors using general and generalized linear mixed regressions, bookkeeping for the nesting of data with random effects. Tukey–Kramer adjustment was used for multiple comparisons. All analysis was conducted using SAS nine.4 (Cary, NC).

RESULTS

Bivariate Analysis Comparing Patient-Centered Medical Home and Soldier-Centered Medical Domicile

Descriptive statistics for soldier demographics by medical home type can be found in Table I. There were 10,307 soldier profiles written in PCMHs and 16,907 in SCMHs. The mean age was 33 (95% CI [32.3, 33.4]) in PCMHs and xxx (95% CI [29.3, 30.half-dozen]) in SCMHs. Total temporary profiles ranged from 1 to 357 days. The mean for all temporary profiles in this written report was 37 days (95% CI [36.2, 37.0]). There was a significant difference in hateful total temporary profile days betwixt PCMHs (43, 95% CI [41.0, 45.8]) and SCMHs (35, 95% CI [32.0, 37.four]) (P < 0.001). There were 1,047 (10%) soldiers with temporary profiles over ninety days within PCMHs and i,162 (seven%) within SCMHs.

Table I.

Descriptive Summary of Soldier Characteristics in the Patient-Centered Medical Dwelling and Soldier-Centered Medical Home

PCMH SCMH
North = 10,307 N = 16,907
Variable Mean (95% CI) Hateful (95% CI) P-value
Age 33 (32.3, 33.iv) 30 (29.3, 30.6) <0.0001
Total Profile Days 43 (41.0, 45.8) 35 (32.0, 37.4) <0.0001
n % north %
Sexual activity <0.0001
Male 7,753 75% 13,530 80%
Female person 2,554 25% 3,377 20%
Race 0.0012
White v,780 56% 10,126 60%
Blackness three,073 xxx% 4,933 29%
Asian/Pacific Islander 700 7% 906 5%
Other 659 6% 778 5%
American Indian or Alaska Native 65 1% 141 1%
Rank Level <0.0001
Junior Enlisted (E1–E5) five,172 50% 10,800 63%
Senior Enlisted (E6–E9) 3,076 xxx% iv,335 26%
Junior Officer (O1–O3) 761 7% 1,044 6%
Senior Officer (O4–O9) 888 9% 319 ii%
Junior Warrant (WO1–CW2) 208 2% 258 2%
Senior Warrant (CW3–CW5) 202 2% 151 1%
Physical Demand Category <0.0001
Moderate vii,430 72% 9,182 54%
Significant one,705 17% 3,036 18%
Heavy ane,160 xi% four,681 28%
Contour Severity Level 0.0002
Mild iv,383 43% 8,244 49%
Moderate 5,367 52% 7,558 45%
Severe 557 5% 1,105 6%
PCMH SCMH
Due north = 10,307 N = 16,907
Variable Hateful (95% CI) Mean (95% CI) P-value
Age 33 (32.iii, 33.4) 30 (29.3, 30.6) <0.0001
Total Profile Days 43 (41.0, 45.viii) 35 (32.0, 37.4) <0.0001
n % due north %
Sex <0.0001
Male seven,753 75% 13,530 fourscore%
Female 2,554 25% 3,377 20%
Race 0.0012
White 5,780 56% 10,126 threescore%
Black 3,073 30% 4,933 29%
Asian/Pacific Islander 700 vii% 906 v%
Other 659 6% 778 5%
American Indian or Alaska Native 65 1% 141 one%
Rank Level <0.0001
Junior Enlisted (E1–E5) 5,172 50% 10,800 63%
Senior Enlisted (E6–E9) three,076 30% iv,335 26%
Junior Officer (O1–O3) 761 7% 1,044 half dozen%
Senior Officer (O4–O9) 888 ix% 319 2%
Junior Warrant (WO1–CW2) 208 2% 258 2%
Senior Warrant (CW3–CW5) 202 ii% 151 i%
Physical Demand Category <0.0001
Moderate 7,430 72% 9,182 54%
Significant 1,705 17% three,036 18%
Heavy ane,160 11% four,681 28%
Profile Severity Level 0.0002
Balmy four,383 43% 8,244 49%
Moderate 5,367 52% 7,558 45%
Severe 557 5% one,105 6%

PCMH = Patient-Centered Medical Home, SCMH= Soldier-Centered Medical Home, CI = Confidence Interval.

Tabular array I.

Descriptive Summary of Soldier Characteristics in the Patient-Centered Medical Domicile and Soldier-Centered Medical Dwelling

PCMH SCMH
N = 10,307 N = 16,907
Variable Mean (95% CI) Hateful (95% CI) P-value
Age 33 (32.3, 33.four) 30 (29.3, 30.6) <0.0001
Total Profile Days 43 (41.0, 45.eight) 35 (32.0, 37.4) <0.0001
n % n %
Sex <0.0001
Male person 7,753 75% thirteen,530 lxxx%
Female 2,554 25% iii,377 20%
Race 0.0012
White v,780 56% ten,126 lx%
Blackness 3,073 xxx% four,933 29%
Asian/Pacific Islander 700 vii% 906 v%
Other 659 six% 778 5%
American Indian or Alaska Native 65 1% 141 one%
Rank Level <0.0001
Junior Enlisted (E1–E5) 5,172 50% 10,800 63%
Senior Enlisted (E6–E9) 3,076 30% 4,335 26%
Junior Officeholder (O1–O3) 761 vii% 1,044 vi%
Senior Officeholder (O4–O9) 888 9% 319 2%
Junior Warrant (WO1–CW2) 208 2% 258 ii%
Senior Warrant (CW3–CW5) 202 ii% 151 1%
Concrete Need Category <0.0001
Moderate vii,430 72% 9,182 54%
Meaning one,705 17% 3,036 eighteen%
Heavy i,160 11% 4,681 28%
Profile Severity Level 0.0002
Mild iv,383 43% 8,244 49%
Moderate five,367 52% 7,558 45%
Severe 557 5% i,105 6%
PCMH SCMH
N = 10,307 N = 16,907
Variable Mean (95% CI) Mean (95% CI) P-value
Age 33 (32.iii, 33.4) 30 (29.iii, 30.6) <0.0001
Total Profile Days 43 (41.0, 45.eight) 35 (32.0, 37.4) <0.0001
northward % due north %
Sex activity <0.0001
Male vii,753 75% 13,530 lxxx%
Female 2,554 25% 3,377 20%
Race 0.0012
White five,780 56% 10,126 threescore%
Blackness 3,073 30% 4,933 29%
Asian/Pacific Islander 700 7% 906 five%
Other 659 half-dozen% 778 5%
American Indian or Alaska Native 65 1% 141 one%
Rank Level <0.0001
Junior Enlisted (E1–E5) five,172 l% 10,800 63%
Senior Enlisted (E6–E9) 3,076 xxx% 4,335 26%
Inferior Officer (O1–O3) 761 seven% 1,044 vi%
Senior Officeholder (O4–O9) 888 9% 319 two%
Junior Warrant (WO1–CW2) 208 2% 258 2%
Senior Warrant (CW3–CW5) 202 two% 151 1%
Concrete Demand Category <0.0001
Moderate 7,430 72% 9,182 54%
Pregnant i,705 17% 3,036 xviii%
Heavy 1,160 11% 4,681 28%
Profile Severity Level 0.0002
Mild iv,383 43% eight,244 49%
Moderate 5,367 52% 7,558 45%
Astringent 557 5% 1,105 vi%

PCMH = Patient-Centered Medical Abode, SCMH= Soldier-Centered Medical Dwelling, CI = Confidence Interval.

Multivariate Analysis of Total Temporary Profile Days and Soldier Characteristics

On average, soldiers one twelvemonth older were associated with 0.3 more temporary profile days, decision-making for other variables (P < 0.001, 95% CI [0.26, 0.42]). Female soldiers had 2.8 more temporary contour days than male soldiers (P < 0.001, 95% CI [1.74, 3.81]). There was no significant departure among races. Junior enlisted soldiers had significantly more temporary profile days than inferior officers and senior enlisted soldiers (P < 0.001, in both cases). Soldiers in the heavy concrete need category had 1.viii fewer temporary profile days than soldiers in the moderate physical demand category (P = 0.0021, 95% CI [−2.91, −0.64]). Soldiers with profiles for severe conditions had 13.nine more temporary profile days than those with mild conditions (P < 0.001, 95% CI [12.07, 15.67]).

Multivariate Assay of Temporary Profiles over xc Days and Soldier Characteristics

On average, soldiers 1 year older were associated with ii% higher odds of having temporary profiles over ninety days (OR = one.02, 95% CI [one.02, i.03]). Female person soldiers were 19% more likely than male soldiers to take temporary profiles over 90 days (OR = 1.21, 95% CI [1.08, 1.36]). Junior officers and senior enlisted soldiers were 30% and 26% less probable than junior enlisted soldiers to accept temporary profiles day over 90 days (OR = 0.74, 95% CI [0.59, 0.91]) and (OR = 0.77, 95% CI [0.67, 0.89]), respectively. Soldiers in the heavy physical demand category were 17% less likely to have profiles over xc days than those in the moderate concrete need category (OR = 0.84, 95% CI [0.73, 0.98]). Soldiers with severe atmospheric condition were 96% more likely to take temporary profiles over 90 days than those with mild weather (OR = ii.61, 95% CI [2.xix, 3.12]).

Predictors of Full Temporary Profile Days in a Multiple General Linear Mixed Regression

Age, sex activity, rank level, physical demand category, profile severity, and medical home blazon were significant predictors of total temporary profile days (P < 0.001) subsequently controlling for other predictors. Race was not a significant predictor of total temporary profile days. The "explicate things" JOES-C patient-centered communication subscale and PCM continuity were also meaning predictors of total temporary contour days (P = 0.0335 and 0.0126, respectively) (see Table 2).

Table II.

Multiple Linear Mixed Regression Model for Predictors of Temporary Profile Days equally a Continuous Variable

2018
Variables Guess 95% CI P-value
Intercept xviii.9150 three.51, 34.32 0.0210
Historic period 0.3386 0.26, 0.42 <0.0001
Medical Home Type 0.0003
SCMH a
PCMH 6.4990 2.97, 10.03 0.0001
Sex <0.0001
Male a
Female person 2.7804 1.75, 3.81 <0.0001
Rank Level <0.0001
Junior Enlisted (E1–E5) a
Junior Officeholder (O1–O3) −3.1324 −four.88, −1.38 0.0005
Junior Warrant (WO1–CW2) −2.2305 −5.54, 1.08 0.1872
Senior Enlisted (E6–E9) −2.8502 −4.06, −1.64 <0.0001
Senior Officer (O4–09) −0.2535 −two.78, 2.27 0.8441
Senior Warrant (CW3–CW5) 1.4010 −two.48, 5.29 0.4797
Concrete Need Category 0.0045
Moderate a
Significant 0.1942 −0.96, one.35 0.7410
Heavy −one.7781 −ii.91, −0.64 0.0021
Race 0.1233
White a
Black 0.03121 −0.92, 0.98 0.9487
Asian/Pacific Islander −ane.9234 −three.seventy, −0.15 0.0336
American Indian or Alaska Native −4.2147 −viii.78, 0.85 0.1067
Other 0.02788 −1.86, ane.91 0.9769
Contour Severity <0.0001
Balmy a
Moderate 4.8866 4.00, 5.77 <0.0001
Severe 13.8727 12.07, 15.67 <0.0001
Access to Intendance
3rd Adjacent Available Date Hereafter 0.3779 0.033, 0.79 0.0716
Third Next Available Appointment 24 60 minutes −0.8914 −3.38, one.60 0.4835
Soldiers' Perception of Access to Care (JOES-C) −1.3093 −2.65, 0.03 0.0559
Continuity
Primary Care Manager Continuity 15.5986 iii.34, 27.86 0.0126
Medical Domicile Team Continuity −iii.1108 −xvi.45, 10.23 0.6477
Soldiers' Perception of Continuity (JOES-C) 0.4073 −0.31, 1.12 0.2658
Communication (JOES-C)
Explain Things ix.1144 0.71, 17.52 0.0335
Listen Advisedly −ane.0831 −fourteen.01, 11.84 0.8695
Spend Enough Time −ii.9836 −9.97, four.01 0.4027
Evidence Respect −5.7256 −18.53, 7.08 0.3809
2018
Variables Estimate 95% CI P-value
Intercept 18.9150 3.51, 34.32 0.0210
Age 0.3386 0.26, 0.42 <0.0001
Medical Home Type 0.0003
SCMH a
PCMH six.4990 2.97, 10.03 0.0001
Sexual activity <0.0001
Male a
Female 2.7804 1.75, 3.81 <0.0001
Rank Level <0.0001
Junior Enlisted (E1–E5) a
Inferior Officer (O1–O3) −3.1324 −4.88, −1.38 0.0005
Inferior Warrant (WO1–CW2) −2.2305 −v.54, one.08 0.1872
Senior Enlisted (E6–E9) −2.8502 −four.06, −1.64 <0.0001
Senior Officer (O4–09) −0.2535 −2.78, 2.27 0.8441
Senior Warrant (CW3–CW5) i.4010 −2.48, 5.29 0.4797
Physical Need Category 0.0045
Moderate a
Significant 0.1942 −0.96, 1.35 0.7410
Heavy −1.7781 −2.91, −0.64 0.0021
Race 0.1233
White a
Blackness 0.03121 −0.92, 0.98 0.9487
Asian/Pacific Islander −1.9234 −3.70, −0.fifteen 0.0336
American Indian or Alaska Native −4.2147 −8.78, 0.85 0.1067
Other 0.02788 −ane.86, i.91 0.9769
Profile Severity <0.0001
Mild a
Moderate 4.8866 iv.00, v.77 <0.0001
Severe 13.8727 12.07, fifteen.67 <0.0001
Access to Care
Tertiary Adjacent Available Engagement Futurity 0.3779 0.033, 0.79 0.0716
3rd Side by side Available Date 24 Hr −0.8914 −3.38, ane.60 0.4835
Soldiers' Perception of Access to Care (JOES-C) −one.3093 −two.65, 0.03 0.0559
Continuity
Primary Care Director Continuity fifteen.5986 three.34, 27.86 0.0126
Medical Home Team Continuity −3.1108 −16.45, 10.23 0.6477
Soldiers' Perception of Continuity (JOES-C) 0.4073 −0.31, 1.12 0.2658
Communication (JOES-C)
Explicate Things nine.1144 0.71, 17.52 0.0335
Listen Carefully −1.0831 −fourteen.01, eleven.84 0.8695
Spend Plenty Fourth dimension −2.9836 −nine.97, 4.01 0.4027
Testify Respect −5.7256 −18.53, seven.08 0.3809

a

= Reference; PCMH = Patient-Centered Medical Home, SCMH= Soldier-Centered Medical Dwelling, CI = Confidence Interval, JOES-C = Joint Outpatient Experience Survey-Consumer Assessment of Healthcare Providers and Systems Clinician and Group.

TABLE Ii.

Multiple Linear Mixed Regression Model for Predictors of Temporary Profile Days as a Continuous Variable

2018
Variables Approximate 95% CI P-value
Intercept xviii.9150 iii.51, 34.32 0.0210
Age 0.3386 0.26, 0.42 <0.0001
Medical Domicile Type 0.0003
SCMH a
PCMH 6.4990 2.97, x.03 0.0001
Sex <0.0001
Male a
Female 2.7804 one.75, 3.81 <0.0001
Rank Level <0.0001
Junior Enlisted (E1–E5) a
Inferior Officer (O1–O3) −three.1324 −4.88, −1.38 0.0005
Junior Warrant (WO1–CW2) −ii.2305 −v.54, 1.08 0.1872
Senior Enlisted (E6–E9) −2.8502 −4.06, −i.64 <0.0001
Senior Officer (O4–09) −0.2535 −2.78, 2.27 0.8441
Senior Warrant (CW3–CW5) i.4010 −two.48, five.29 0.4797
Concrete Need Category 0.0045
Moderate a
Significant 0.1942 −0.96, 1.35 0.7410
Heavy −1.7781 −2.91, −0.64 0.0021
Race 0.1233
White a
Blackness 0.03121 −0.92, 0.98 0.9487
Asian/Pacific Islander −1.9234 −three.lxx, −0.15 0.0336
American Indian or Alaska Native −4.2147 −8.78, 0.85 0.1067
Other 0.02788 −1.86, ane.91 0.9769
Profile Severity <0.0001
Mild a
Moderate 4.8866 four.00, 5.77 <0.0001
Severe 13.8727 12.07, 15.67 <0.0001
Access to Care
Tertiary Adjacent Available Appointment Hereafter 0.3779 0.033, 0.79 0.0716
Third Adjacent Available Appointment 24 Hour −0.8914 −3.38, 1.sixty 0.4835
Soldiers' Perception of Admission to Intendance (JOES-C) −1.3093 −ii.65, 0.03 0.0559
Continuity
Primary Care Manager Continuity xv.5986 3.34, 27.86 0.0126
Medical Home Team Continuity −3.1108 −xvi.45, x.23 0.6477
Soldiers' Perception of Continuity (JOES-C) 0.4073 −0.31, 1.12 0.2658
Communication (JOES-C)
Explain Things 9.1144 0.71, 17.52 0.0335
Listen Carefully −i.0831 −14.01, eleven.84 0.8695
Spend Enough Time −2.9836 −9.97, iv.01 0.4027
Testify Respect −five.7256 −eighteen.53, 7.08 0.3809
2018
Variables Estimate 95% CI P-value
Intercept 18.9150 3.51, 34.32 0.0210
Historic period 0.3386 0.26, 0.42 <0.0001
Medical Dwelling house Type 0.0003
SCMH a
PCMH 6.4990 2.97, x.03 0.0001
Sex <0.0001
Male person a
Female person two.7804 1.75, 3.81 <0.0001
Rank Level <0.0001
Junior Enlisted (E1–E5) a
Junior Officeholder (O1–O3) −3.1324 −four.88, −1.38 0.0005
Inferior Warrant (WO1–CW2) −2.2305 −five.54, 1.08 0.1872
Senior Enlisted (E6–E9) −ii.8502 −four.06, −1.64 <0.0001
Senior Officer (O4–09) −0.2535 −two.78, ii.27 0.8441
Senior Warrant (CW3–CW5) 1.4010 −2.48, 5.29 0.4797
Physical Need Category 0.0045
Moderate a
Pregnant 0.1942 −0.96, one.35 0.7410
Heavy −1.7781 −2.91, −0.64 0.0021
Race 0.1233
White a
Black 0.03121 −0.92, 0.98 0.9487
Asian/Pacific Islander −i.9234 −3.70, −0.15 0.0336
American Indian or Alaska Native −4.2147 −eight.78, 0.85 0.1067
Other 0.02788 −1.86, 1.91 0.9769
Profile Severity <0.0001
Mild a
Moderate 4.8866 4.00, 5.77 <0.0001
Astringent xiii.8727 12.07, 15.67 <0.0001
Access to Care
Third Next Available Appointment Future 0.3779 0.033, 0.79 0.0716
Third Next Available Appointment 24 60 minutes −0.8914 −three.38, one.60 0.4835
Soldiers' Perception of Access to Intendance (JOES-C) −1.3093 −2.65, 0.03 0.0559
Continuity
Main Care Managing director Continuity 15.5986 3.34, 27.86 0.0126
Medical Home Team Continuity −3.1108 −16.45, ten.23 0.6477
Soldiers' Perception of Continuity (JOES-C) 0.4073 −0.31, ane.12 0.2658
Communication (JOES-C)
Explain Things 9.1144 0.71, 17.52 0.0335
Listen Carefully −1.0831 −14.01, xi.84 0.8695
Spend Enough Fourth dimension −two.9836 −9.97, 4.01 0.4027
Show Respect −v.7256 −eighteen.53, seven.08 0.3809

a

= Reference; PCMH = Patient-Centered Medical Home, SCMH= Soldier-Centered Medical Home, CI = Confidence Interval, JOES-C = Articulation Outpatient Experience Survey-Consumer Assessment of Healthcare Providers and Systems Clinician and Group.

Predictors of Temporary Profiles over 90 Days in a Multiple Generalized Linear Mixed Regression

We establish that medical dwelling house type was a significant predictor of temporary profiles over 90 days (P < 0.001), controlling for other predictors. Specifically, soldiers in PCMHs were 65% more probable to accept profiles over 90 days than those in SCMHs (OR = one.54, 95% CI [i.17, 2.03]). As well, historic period, sex, rank level, and profile severity were meaning predictors of temporary profiles over 90 days (P < 0.001). Race and physical demand were non significant predictors of temporary profiles over 90 days. The soldiers' perception of admission to intendance, PCM continuity, and the "explain things" JOES-C communication subscale were significant predictors of temporary profiles over ninety days (run across Fig. 2).

Figure ii.

Forest plot showing predictors of total temporary profiles over ninety days. A generalized linear mixed regression model with historic period, sex, rank level, physical demand category, race, profile severity, medical domicile type, access to hereafter appointments, access to 24 60 minutes appointments, soldiers' preception of access to care, primary care manager continuity, medical abode squad continuity, soldiers' perception of continuity, and Joint Outpatient Experience Survey communication subscales

Wood plot showing predictors of total temporary profiles over 90 days. A generalized linear mixed regression model with age, sexual activity, rank level, physical need category, race, profile severity, medical dwelling type, access to time to come appointments, access to 24 hour appointments, soldiers' preception of access to intendance, principal care manager continuity, medical dwelling house squad continuity, soldiers' perception of continuity, and Joint Outpatient Feel Survey advice subscales "explain things," "mind carefully," "spend enough time," and "respect" as covariants was performed. The regression yielded age, sex, rank level, profile severity, medical dwelling type, soldiers' perception of admission to intendance, primary care manager continuity, and the Joint Outpatient Experience Survey advice subscale "explain things" as significant predictors of temporary profiles over 90 days (P < 0.05). The odds ratios (OR), confidence intervals (LCL-UCL), and P-values (P) are shown.

FIGURE 2.

Forest plot showing predictors of total temporary profiles over xc days. A generalized linear mixed regression model with age, sex, rank level, physical demand category, race, profile severity, medical home type, access to future appointments, access to 24 hr appointments, soldiers' preception of access to care, primary care manager continuity, medical home team continuity, soldiers' perception of continuity, and Joint Outpatient Experience Survey communication subscales

Woods plot showing predictors of total temporary profiles over 90 days. A generalized linear mixed regression model with age, sexual practice, rank level, physical demand category, race, profile severity, medical home type, access to futurity appointments, access to 24 hour appointments, soldiers' preception of access to intendance, primary care manager continuity, medical domicile team continuity, soldiers' perception of continuity, and Joint Outpatient Feel Survey communication subscales "explain things," "listen advisedly," "spend enough fourth dimension," and "respect" every bit covariants was performed. The regression yielded age, sex, rank level, contour severity, medical domicile type, soldiers' perception of access to intendance, primary care manager continuity, and the Articulation Outpatient Experience Survey communication subscale "explain things" as pregnant predictors of temporary profiles over 90 days (P < 0.05). The odds ratios (OR), confidence intervals (LCL-UCL), and P-values (P) are shown.

Give-and-take

This is the first report to compare an important soldier health outcome, temporary profiles days betwixt PCMHs and SCMHs and examine the influence of medical home team structures and care processes on temporary profile days. We establish that soldier demographics and temporary profile days differ significantly between PCMHs and SCMHs. We also establish that structures and processes influenced this soldier event, offering back up for Donabedian's conceptual framework. The goal is fewer temporary profile days and a lower likelihood of having temporary profiles over xc days. Existence assigned to an SCMH, higher "explain things" communication subscales scores, higher perception of access to care, better PCM continuity, lower historic period, male sexual activity, higher rank, college physical demand in the task, and lower profile severity were predictors of fewer full temporary profile days. These variables, except physical demand, were also predictors of a lower likelihood of temporary profiles over xc days.

Measuring Temporary Profile Days

Previous studies estimated temporary profile days by imputed dates, 28,29 self-reported survey data, 30,31 medical tape documentation from visits for MSIs, or multiplying the frequency of visits for an MSI past standard recovery times. 5,32,33 These may be more than conservative estimates of profile days. We calculated temporary profile days based on the start and end dates of profiles documented in the e-Profile system. This was possible, in role, as a upshot of upgrades to and consequent documentation in the e-Contour system and revisions to U.S. Army policies governing medical readiness, 11,12 making profile data collection and evaluation more than accurate. Farther improvements to the e-Profile system could facilitate future research to enhance temporary profile management.

Soldier Characteristics

Our results align with previous studies that reported age, 30,33,34 sex, 28,30 and physical demand of occupational tasks 13,28,29,34 as influencers of temporary profiles days. These findings are crucial every bit we consider the impact of the new Army Combat Fitness Test (ACFT) and possible assessment criteria based on concrete demand category and sexual practice, with no regard to age. The U.Southward. Army continues to assemble data to finalize the new ACFT standards. Since physical training activities cause most MSIs, 6,34 policymakers should consider the result of new ACFT requirements on female soldiers, soldiers of higher age, and soldiers in the moderate physical demand category. These soldiers are already at increased take a chance for injury 34 and temporary contour days.

Admission

Researchers previously reported associations betwixt access to care and returning to work and full functioning afterwards an acute injury. 18 In this study, a higher perception of access was associated with fewer temporary profile days. There may exist many factors influencing a soldier's perceived ability to access intendance for acute issues. Soldiers depend heavily on leaders to back up their requests to seek medical attending for acute conditions because they may not simply call in for a "sick day." Additionally, the notion of military "toughness" underpinned by the warrior ethos 35 and wellness behaviors among soldiers may also influence their requests for appointments. Our results support the need for future qualitative exploration of barriers and facilitators to soldiers' perception of admission (e.yard., logistical factors, leadership support, and help-seeking behaviors) and means to improve it, including innovative virtual and mobile options. Farther exploration could assist generate mitigation strategies for Army leaders.

Continuity

Researchers have reported that PCM continuity, i.due east., when patients see their assigned PCM, improves patient outcomes. 36,37 We found that PCM continuity was associated with fewer temporary profile days. Given the challenges of maintaining PCM continuity within the military, 15 the Military Health Organisation (MHS) must foster innovative ways to maintain continuity of data as providers and soldiers motion around. The total implementation of MHS Genesis, the new MHS electronic medical tape, might further ameliorate information exchange among military machine hospitals and clinics. Additionally, continuous improvements to the due east-Profile system may likewise enhance data continuity. This is another area for future research.

Communication

College JOES-C "explicate things" subscale scores among soldiers were associated with fewer full temporary profiles days. Although, provider communication scores include all provider types, e.g., nurse, physician, and concrete therapists, advice within the medical domicile is a team effort. These findings nowadays an opportunity to discuss the essential role of nurses in the medical abode. 38 Articulate advice between the healthcare team and soldiers aligns recovery expectations, addresses barriers, and facilitates adherence to treatment plans and profile limitations that helps decrease temporary profile days. Nurses contribute to enhanced communication past post-obit upwards later on an injury to reinforce instruction and wellness coaching and facilitate coordination for follow-upward intendance when needed. 39 Nurses are as well vital to ensuring that members of the healthcare team, leaders, and soldiers accept a clear agreement of the soldier's treatment plan, injury status, and prognosis, contributing greatly to medical readiness. 39 Efforts should exist made to explore patient-centered communication among soldiers in future qualitative studies. Hereafter studies should likewise test strategies such as nurse-led education and health literacy interventions aligned with the Ground forces Medical Home Roles and Responsibilities guidelines. 40

Limitations

There are the following four limitations to consider: the utilize of secondary information, cantankerous-sectional design, potential confounders, and generalizability of study results. Limitations of the extracted data did not permit us to exclude temporary profile records for circuitous conditions such as fractures and compartment syndrome. These atmospheric condition require possible surgical intervention and all-encompassing recovery times, which could have confounded our results. Our cross-sectional design does not allow united states of america to describe any causal links between structural attributes, care processes, and soldier outcomes. However, we considered this cantankerous-exclusive study a logical first step since no other written report has focused on this combination of variables.

There were unobserved variables that could take confounded our results, such as other aspects of the intendance environs, armed forces operational cycle, and military culture. There are no standardized measures for armed forces civilization, merely previous enquiry suggests that factors such as military rank structure, customs and courtesies, profile stigma, and career advancement could underpin healthcare assistants and behaviors in the military. 40 Finally, many occupational specialties in the U.South. Ground forces are equivalent to civilian occupations; however, there are differences in overall military machine and civilian workforce requirements. While these results may be generalizable to other military services generalizations to workforces outside the military should be cautiously made.

CONCLUSIONS

Excessive temporary contour days threaten medical readiness and overall soldier health. Aspects of the medical domicile construction and care processes were predictors of temporary profile days for musculoskeletal atmospheric condition. Because the direct intendance costs of MSIs within the military and the impact of MSIs on health and long-term medical disability, this work supports continued efforts to ameliorate MSI-related outcomes among soldiers.

Future studies should examine: temporary profile days and soldier characteristics in a longitudinal analysis; the soldier' perception of access in qualitative analysis; whether continuity is influenced more by appointing practices, patient preference, or provider unavailability; the soldiers' experience with communication in the medical dwelling in qualitative assay; and the influence of a nurse-led intervention for health literacy and didactics on soldier knowledge, temporary profile days, and medical readiness. Knowledge gained from this study tin can guide futurity research questions, help the Regular army ameliorate meet soldier needs, and ultimately help soldiers attain their overall health goals.

ACKNOWLEDGMENT

None declared.

FUNDING

This study was supported by the TriService Nursing Research Program (Grant Number: 11052-N2003-GR, Project #N20A03GR). The U.S. Regular army Medical Department Heart & School Institutional Review Lath (Protocol #twenty-08975) and The University of Alabama at Birmingham Institutional Review Board (Protocol #300005151) approved this written report on March 8, 2020 and April 22, 2020, respectively.

CONFLICT OF Involvement Statement

None declared.

REFERENCES

1.

Defence Health Bureau

:

2018 stakeholder study

.

Defense Health Agency

;

2020

.

3.

U.Southward. Army Medical Department

:

Leaders Guide to Army Soldier-Centered Medical Home Transformation

.

U.Southward. Ground forces Medical Department

;

2014

.

4.

Sapp

JE

,

Cody

MJ

,

Douglas

KM

:

Changes in temporary inability reporting following the implementation of the ground forces medical readiness transformation

.

Mil Med

2018

;

183

(

7–8

):

e179

–

83

.

5.

Teyhen

DS

,

Shaffer

SW

,

Butler

RJ

, et al. :

What chance factors are associated with musculoskeletal injury in Usa Army rangers? A prospective prognostic study

.

Clin Orthop Relat Res

2015

;

473

(

9

):

2948

–

58

.

6.

Canham-Chervak

Grand

,

Rappole

C

,

Grier

T

,

Jones

B

:

Injury mechanisms, activities, and limited work days in the U.S. Army infantry unit of measurement

.

US Regular army Med Dep J

2018

;

viii

(

eighteen

):

six

–

13

.

7.

Smith

L

,

Westrick

R

,

Sauers

S

, et al. :

Underreporting of musculoskeletal injuries in the US Army

.

Sports Health

2016

;

viii

(

6

):

507

–

13

.

8.

Jones

BH

,

Hauschild

VD

:

Physical training, fitness, and injuries: lessons learned from military studies

.

J Forcefulness Cond Res

2015

;

29

(

Suppl 11

):

S57

–

64

.

10.

U.S. Section of Veterans Diplomacy

:

United states of americaDepartment of Veterans Affairs: veterans benefits assistants. Annual benefits report

.

Fiscal Year 2018

.

U.S. Department of Veterans Affairs

;

2018

.

11.

Section of the Army

:

Ground forces regulation twoscore-502. Medical services

.

Medical readiness

.

Washington, DC

,

Headquarters, Section of the Regular army

;

2019

.

12.

Department of the Army

:

Department of the Army Pamphlet 40-502. Medial services

.

Medical Readiness Procedures

.

Washington, DC

:

Headquarters, Department of the Army

;

2019

.

xiii.

Teyhen

DS

,

Goffar

SL

,

Shaffer

SW

, et al. :

Incidence of musculoskeletal injury in US Army unit types: a prospective cohort study

.

J Orthop Sports Phys Ther

2018

;

48

(

x

):

749

–

57

.

14.

Malish

RG

,

Arnett

AD

,

Place

RJ

:

Returning to duty from temporary disability in the U.S. Ground forces: observational data and commentary for commanders, providers, and soldiers

.

Mil Med

2014

;

179

(

11

):

1190

–

vii

.

15.

Christensen

EW

,

Dorrance

KA

,

Ramchandani

South

, et al. :

Touch of a patient-centered medical dwelling on admission, quality, and toll

.

Mil Med

2013

;

178

(

2

):

135

–

41

.

17.

Alexander

JA

,

Hearld

LR

:

Methods and metrics challenges of delivery-system inquiry

.

Implement Sci

2012

;

seven

(

1

): xv.

18.

Hu

J

,

Jiang

Y

,

Liang

Y

,

Yu

ITS

,

Leng

H

,

He

Y

:

Predictors of return to work and duration of absence following piece of work-related paw injury

.

Int J Inj Contr Saf Promot

2014

;

21

(

3

):

216

–

23

.

xix.

McLellan

RK

,

Haas

NS

,

Kownacki

RP

,

Pransky

GS

,

Talmage

JB

,

Dreger

1000

:

Using electronic health records and clinical decision support to provide return-to-piece of work guidance for master care practitioners for patients with low back pain

.

J Occup Environ Med

2017

;

59

(

11

):

e240

–

iv

.

twenty.

Jurisic

Thou

,

Edible bean

1000

,

Harbaugh

J

, et al. :

The personal physician's role in helping patients with medical conditions stay at work or render to work

.

J Occup Environ Med

2017

;

59

(

6

):

e125

–

31

.

21.

Donabedian

A

:

Evaluating the quality of medical care

.

Milbank Mem Fund Q

1966

;

44

(

3

):

166

–

206

.

22.

The states Department of Health and Human being Services

:

Consumer assessment of healthcare providers and systems

.

Agency for Healthcare Research and Quality

;

2010

.

24.

McGee

J

,

Kanouse

DE

,

Sofaer

South

,

Hargraves

JL

,

Hoy

Due east

,

Kleimann

S

:

Making survey results easy to report to consumers: how reporting needs guided survey design in CAHPS

.

Med Care

1999

;

37

(

3

):

MS32

–

40

.

25.

Dyer

N

,

Sorra

JS

,

Smith

SA

,

Cleary

PD

,

Hays

RD

:

Psychometric properties of the Consumer Cess of Healthcare Providers and Systems (CAHPS®) Clinician and Group Developed Visit Survey

.

Med Care

2012

;

50

(

Suppl

):

S28

–

34

.

26.

Rodriguez

HP

,

Crane

PK

:

Examining multiple sources of differential item functioning on the Clinician & Grouping CAHPS® survey

.

Health Serv Res

2011

;

46

(

6pt1

):

1778

–

802

.

27.

Department of the Army

:

Pamphlet 611–21: personnel option and nomenclature. Armed services occupational classification and construction

.

Washington, DC

:

Headquarters, Department of the Regular army

;

2018

.

28.

Holsteen

KK

,

Choi

YS

,

Bedno

SA

,

Nelson

DA

,

Kurina

LM

:

Gender differences in limited duty time for lower limb injury

.

Occup Med

2018

;

68

(

1

):

18

–

25

.

29.

Reynolds

Thou

,

Cosio-Lima

Fifty

,

Bovill

K

,

Tharion

W

,

Williams

J

,

Hodges

T

:

A comparing of injuries, express-duty days, and injury risk factors in infantry, artillery, construction engineers, and special forces soldiers

.

Mil Med

2009

;

174

(

seven

):

702

–

8

.

30.

Feuerstein

M

,

Berkowitz

SM

,

Haufler

AJ

,

Lopez

MS

,

Huang

GD

:

Working with low back hurting: workplace and individual psychosocial determinants of express duty and lost time

.

Am J Ind Med

2001

;

40

(

half dozen

):

627

–

38

.

31.

Jennings

BM

,

Yoder

LH

,

Heiner

SL

,

Loan

LA

,

Bingham

MO

:

Soldiers with musculoskeletal injuries

.

J Nurs Scholarsh

2008

;

40

(

three

):

268

–

74

.

32.

Ruscio

BA

,

Jones

BH

,

Bullock

SH

, et al. :

A procedure to identify military injury prevention priorities based on injury type and limited duty days

.

Am J Prev Med

2010

;

38

(

ane Suppl

):

S19

–

33

.

33.

Anderson

MK

,

Grier

T

,

Hauschild

V

,

Jones

BH

:

Injury rates, limited duty days, medically not ready rates, and injury risk factors in an army chemical brigade

.

2015

.

34.

Molloy

JM

,

Pendergrass

TL

,

Lee

IE

,

Hauret

KG

,

Chervak

MC

,

Rhon

DI

:

Musculoskeletal injuries and usa ground forces readiness. part II: management challenges and run a risk mitigation initiatives

.

Mil Med

2020

;

185

(

9–ten

):

e1461

–

71

.doi:

.

35.

Riccio

G

,

Sullivan

R

,

Klein

G

,

Salter

M

,

Kinnison

H

:

Warrior ethos: assay of the concept and initial evolution of applications

.

US Dept of the Ground forces

;

2004

. doi:

36.

Gleason

JL

,

Brook

KH

:

Examining associations between relocation, continuity of intendance, and patient satisfaction in armed forces spouses

.

Mil Med

2017

;

182

(

5

):

e1657

–

64

.

37.

Nelson

Yard

,

Sun

H

,

Dolan

E

, et al. :

Elements of the patient-centered medical home associated with health outcomes among veterans: the function of main care continuity, expanded admission, and care coordination

.

J Ambul Care Manage

2014

;

37

(

4

):

331

–

eight

.

38.

Tomcavage

J

,

Littlewood

D

,

Salek

D

,

Sciandra

J

:

Advancing the role of nursing in the medical abode model

.

Nurs Adm Q

2012

;

36

(

3

):

194

–

202

.

39.

Department of the Army

:

Army Medical Home roles and responsibilities manual

.

2017

.

40.

Fandre

MN

:

The promises and perils of the MHS' implementation of the patient-centered medical dwelling

.

Mil Med

2012

;

177

(

12

):

1445

–

7

.

Author notes

The views expressed are solely those of the authors and exercise not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the Department of Defence, or the U.South. Regime. The U.S. Army Medical Heart of Excellence, Public Affairs Part canonical this manuscript for public release.

Published by Oxford University Press on behalf of the Clan of Military Surgeons of the United States 2022. This work is written by (a) U.s. Government employee(s) and is in the public domain in the US.

This work is written by (a) US Authorities employee(s) and is in the public domain in the US.