Background Eating disorders (ED) and sexual assault (SA) commonly co-occur and are frequently encountered in primary care and gynecological practice. Whether adolescents and young adults (AYA) with ED and co-occurring post-traumatic stress disorder (PTSD), or both PTSD/SA, have greater psychiatric care needs than those with ED alone is unknown. In particular, military-affiliated AYA, a large and diverse population who receive healthcare in military and civilian settings, may be at risk for mental health challenges. We aimed to determine if SA, above and beyond PTSD, is associated with greater rates of mood and anxiety disorders and selective serotonin reuptake inhibitor (SSRI) prescription in military-affiliated AYA with ED. Methods This retrospective cohort study reviewed electronic medical records and TRICARE claims from the US Military Health System from 2016-2023. We identified military-affiliated dependent AYA aged 15-21y, excluding spouses, with an ICD-10-CM code indicating ED. People were considered to have a PTSD or SA diagnosis if they had a relevant ICD-10-CM code at a clinical visit, and a SSRI if prescribed during the study period. Chi-square analyses and odds ratios (OR) compared differences in mood and anxiety disorder diagnoses, and SSRI prescriptions among AYA with ED, ED+PTSD, or ED+PTSD+SA diagnoses. The first author’s IRB approved this protocol. Results Of the 7490 AYA with an ED (55% 15-17y, 87% female, 18% White, 28% non-Hispanic, enrollment M/SD=6±2y), 1446 (19.3%) had ED+PTSD and 201 (2.7%) had ED+PTSD+SA. Groups differed on rates of mood and anxiety disorders and SSRI prescription (ps< .01). Of those with an ED alone, 76% had an anxiety disorder, 69% a mood disorder, and 64% a SSRI prescription indicating additional mental healthcare needs. Compared to AYA with ED, those with ED+PTSD were more likely to have these indicators (mood: 95%, OR=7.9, p< .01; anxiety: 93% OR=4.3, p< .01; SSRI prescription: OR=3.4, p< 0.01), as were those with ED+PTSD+SA (mood 97%, OR=14.9, p< .01; anxiety 99%, OR=21, p< .01; SSRI prescription: OR=7.4, p< 0.01). Furthermore, compared to AYA with ED+PTSD, those with ED+PTSD+SA were more likely to have these indicators (anxiety: OR=4.8, p=.01; mood: OR=1.9, p=.18; SSRI prescription (OR=2.19, p=.01). Conclusion Rates of mood and anxiety disorders and SSRI prescription are significantly higher, up to 20-fold, in military-affiliated AYA with ED who have additional trauma-related diagnoses. Ensuring trauma-informed care and timely access to specialty services for AYA with ED, and particularly those with prior SA, is crucial.

Abstract Introduction Insomnia and obstructive sleep apnea (OSA) are highly prevalent among active-duty U.S. military personnel, and co-occurrence of the conditions is common. Compared to either condition alone in civilian populations, comorbid insomnia and OSA (COMISA) is associated with worse health outcomes, greater healthcare resource utilization, and higher healthcare costs. The purpose of this study was to determine the economic burden of COMISA among active-duty military personnel. We hypothesized that relative to insomnia and OSA alone COMISA is associated with greater healthcare resource utilization and costs. Methods Data were derived from the Military Data Repository (MDR) from 2016-2021. Inclusion criteria were age < 65 years, active-duty military personnel, 12 months of continuous enrollment before and after insomnia or OSA diagnosis, and no evidence of prior insomnia or OSA. COMISA was defined as receipt of an insomnia diagnosis within 365 days of OSA diagnosis. Generalized linear models with log link were used to compare direct costs between individuals without sleep disorders, insomnia alone, OSA alone, or COMISA across multiple points of service: outpatient, inpatient, and emergency department (ED). Costs were adjusted for age, sex, military service, region, comorbidities and prior year costs. Results The final sample included n=183,961 active-duty military personnel without sleep disorders, n=40,278 with insomnia alone, n=27,103 with OSA alone, and n=3,956 with COMISA. Most participants were between ages 35-44 years (40.7%), and male (82.1%). Average adjusted outpatient costs were highest in the COMISA group (without sleep disorders: $4,036; insomnia alone: $9,940; OSA alone: $6,910; COMISA: $10,759; p< 0.001), as were average adjusted ED costs (without sleep disorders: $214; insomnia alone: $363; OSA alone: $395; COMISA: $500; p< 0.001), while average adjusted inpatient costs (without sleep disorders: $168; insomnia alone: $267; OSA alone: $3; COMISA: $169; p< 0.001) were highest in the insomnia group. Conclusion Relative to military personnel without sleep disorders, with insomnia alone, or with OSA alone, individuals with COMISA incur greater inpatient, outpatient, and ED costs. Future research should examine the effect of sleep disorders treatments on health and economic burden as well as military readiness in the U.S. military. Support (if any) U.S. Department of Defense, Military Health System Research Program, HT94022210006.

Insomnia disorder is common among U.S. military personnel and negatively impacts health and military readiness. Among civilians, insomnia is associated with substantial economic burden; yet, little is known about the burden of insomnia within the US Military Health System (MHS). The MHS is a large, integrated healthcare delivery system with worldwide operations and thus ideal for health services research. This study aimed to determine the association between insomnia disorder and healthcare resource utilization (HCRU) in the MHS. Our data source was the Military Data Repository (MDR) between years 2016-2021. This large data repository includes encounter, procedure, medication, and durable medical equipment information for active-duty military personnel, military dependents, National Guard, and Reserves. Demographic and military information was obtained from the MDR. Inclusion criteria were age < 65 years, active-duty military personnel, 12 months of continuous enrollment before and after first insomnia diagnosis (i.e., the index date), and no evidence of insomnia during the 12 months prior to first diagnosis. Insomnia and comorbid medical and psychiatric conditions were defined based on International Classification of Disease-10th Edition codes. Beneficiaries with insomnia were matched 1:1 with non-insomnia controls on >20 demographic, military, and medical and psychiatric comorbidity variables. Mixed effects models were used to compare non-insomnia related HCRU between groups across multiple points of service: outpatient, inpatient, and emergency department (ED). We identified 40,978 MHS beneficiaries with insomnia and 40,978 matched non-insomnia controls. Most (35.9%) beneficiaries with insomnia were between ages 25-34 years, and 20.7% were women. 4.2% of beneficiaries with insomnia had one comorbid medical or psychiatric condition, and 1% had >2 comorbid conditions. Relative to matched non-insomnia controls, beneficiaries with insomnia demonstrated greater 12-month HCRU at every point of service (all p values< 0.001). The incident rate ratio for non-insomnia inpatient visits was RR (95% CI) = 1.96 (1.85,2.08); for non-insomnia outpatient visits was 2.24 (2.23,2.24); and for non-insomnia related ED visits was 1.60 (1.57,1.63). Insomnia is associated with substantially increased healthcare resource utilization in the US military health system. Future research should seek to advance personalized medicine approaches to improve outcomes of evidence-based insomnia care. U.S. Department of Defense HT94022210006.

Background Polycystic ovary syndrome (PCOS), a common endocrine disorder among females, is linked to poorer mental health. Given the stressors experienced by military families (e.g., parental deployment), military-affiliated adolescents and young adults with PCOS (AYA-PCOS) may have a high risk for mental health challenges. Yet, rates of psychiatric diagnoses among this population are unknown. This study aimed to compare rates of psychiatric diagnoses and prescriptions for psychotropic medications between military-affiliated AYA with and without PCOS. Methods This retrospective matched cohort study reviewed electronic medical records and TRICARE insurance claims from the US Military Health System from 2016-2023. Female dependents aged 15-21y with a PCOS diagnosis (ICD-10 code E28.2x) were identified. Spouses were excluded. Five age-matched controls for each AYA-PCOS were also identified. People were considered to have a psychiatric diagnosis if they had any clinical visits associated with a diagnosis, and a psychiatric medication if they had any days’ supply of a medication. Odds ratio (OR) 95% confidence intervals were computed to compare AYA-PCOS and controls. This study was approved by the institutional review board at the last author’s institution. Results We identified 6,877 AYA-PCOS (61% 18-21y, 15% White, 24% non-Hispanic, enrollment M/SD=6/2y) and 35,814 controls (67% 18-21y, 11% White, 21% non-Hispanic, enrollment M/SD=6/2y). Compared to controls, AYA-PCOS had a greater odds of having a psychiatric diagnosis (67%, OR=2.4-2.6), and anxiety (52%, OR=2.2-2.4), mood (45%, OR=2.3-2.5), post-traumatic stress (10%, OR=2.4-2.9), eating (5%, OR=2.2-2.8), or bipolar (8%, OR=2.2-2.7) disorder. More AYA-PCOS were prescribed a psychiatric medication than controls (55%, OR=2.0-2.3). The most frequently prescribed psychotropics to AYA-PCOS were selective serotonin reuptake inhibitors (41%, OR=1.9-2.1), buspirone (23%, OR=1.8-2.1), hydroxyzine (19%, OR=1.8-2.0), and stimulants (15%, OR=1.7-2.0). Conclusions Among military-affiliated AYA, rates of psychiatric diagnosis and psychotropic prescription are more than two times higher among AYA with than without PCOS. The observed rates of psychiatric diagnoses may be higher than documented rates among civilians with PCOS. Little is known about psychotropic medication prescription among civilians with PCOS; thus, it is unclear whether military status impacts psychiatric medication practices among AYA-PCOS. Ensuring adequate access to psychological support for military-affiliated AYA-PCOS is crucial for the health of the military and their families.

PURPOSE:To study rates of psychiatric diagnoses and psychotropic medication prescription among U.S. military-affiliated adolescents and young adults (AYA) with polycystic ovary syndrome (PCOS). METHODS:This retrospective matched cohort study included U.S. military-affiliated AYA (aged 15-21 years) enrolled in TRICARE Prime for at least 6 months during the surveillance period (January 2016 to October 2023). Military-affiliated AYA were grouped into three categories: individuals diagnosed with PCOS (N = 6,911), age-matched individuals with no diagnosed PCOS symptoms (N = 35,814), and individuals with diagnosed symptoms suggestive of PCOS (N = 2,136). The presence of a psychiatric diagnoses and prescriptions for psychotropic medications were obtained via the International Classification of Diseases, 10th Revision, Clinical Modification codes and National Drug codes, respectively. RESULTS:AYA with diagnosed PCOS had higher odds of having a psychiatric diagnosis and being prescribed a psychotropic medication compared to an age-matched comparison group (psychiatric diagnosis odds ratio [OR] = 2.48 [2.35-2.62], medication OR = 2.14 [2.03-2.25]) and individuals with symptoms suggestive of PCOS (psychiatric diagnosis OR = 1.11 [1.003-1.23], medication OR = 1.16 [1.05-1.28]). DISCUSSION:The odds of psychiatric comorbidities and psychotropic medication prescription were more than twice as high as among U.S. military-affiliated AYA with PCOS. More research is needed to determine whether health-care utilization and military-related factors impact mental health outcomes among AYA with PCOS. Additionally, tailored, multidisciplinary mental health services for AYA with PCOS are needed.

This study examined demographic and military factors related to probability of hospitalization among military-affiliated adolescents and young adults (AYA) with an eating disorder (ED) diagnosis. Participants were military-affiliated AYA (spouses not included), ages 10-26 years. De-identified data were extracted from the Military Health System Data Repository from 2016-2021. Kaplan-Meier risk estimates determined the proportion of participants with a hospitalization following their initial ED diagnosis across time. Cox proportional hazard models evaluated adjusted associations of demographic and military-specific factors with probability of hospitalization. Of 7,705 participants with an ED diagnosis, approximately one in five (n = 1,569) had a hospitalization during the study period. Weight categories were only recorded for 35% (n = 2,675) of participants. Adjusting for other variables, hospitalization was more likely for: participants 15-17 years old (versus other age groups), females (versus males), those with underweight (versus higher weights), those who received care at civilian facilities (versus directly within the Military Health System), and those with a parent serving in the Navy (versus the Army). There was no significant difference by ED diagnosis. Results indicate disparities related to hospitalization among AYA with EDs within the Military Health System. More research is needed to understand access to and engagement with ED-related healthcare among military-affiliated AYA.

STUDY OBJECTIVE:Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among people who menstruate. Adolescent and young adult (AYA) military dependents, a large, diverse subset of the United States population, have not been represented in prior reports of PCOS. This study estimated the incidence and prevalence of possible-PCOS (PCOS symptoms in the absence of a documented PCOS diagnosis) and PCOS in AYA military dependents, and described the length of time between possible-PCOS and first documented PCOS diagnosis for people who met both during the surveillance period. METHODS:This retrospective cohort study reviewed military electronic medical records and TRICARE insurance claims from the US Military Health System from 2018 to 2022. We identified female dependents aged 15-21 years with PCOS (International Classification of Diseases, 10th edition (ICD-10); code E28.2x) or possible-PCOS (i.e., having both androgen excess and a amenorrhea or oligomenorrhea ICD-10 code within a 12-month period) who received care through TRICARE due to insurance sponsor's military service. RESULTS:A total of 8385 AYA military dependents had PCOS or possible-PCOS. Across the 5-year period, the average yearly incidence was 59/10,000 people (range 54-64). The average yearly prevalence was 182/10,000 people (range 159-195) and was lowest among Black (139/10,000 people) and Asian (132/10,000 people) AYA. CONCLUSION:Rates of PCOS in AYA military dependents are comparable to rates estimated from medical record data in US civilian populations. Identifying barriers to PCOS detection could facilitate earlier treatment access for military dependents.

BACKGROUND:Polycystic ovary syndrome (PCOS) is a chronic medical condition characterized by ovulatory dysfunction, hyperandrogenism, and/or polycystic ovary morphology. Data on rates of PCOS among active-duty service members (ADSMs) are limited, despite high risk for medical comorbidities (e.g., obesity, type 2 diabetes) that could negatively impact ADSMs' health and military careers. This study aimed to describe the incidence and prevalence of PCOS and possible PCOS (i.e., both ovulatory dysfunction and hyperandrogenism) among ADSMs. METHODS:This retrospective cohort study accessed data from the Military Health System Data Repository between 2018 and 2022. ADSMs with a PCOS International Classification of Diseases, 10th Revision (ICD-10) code or ICD-10 codes indicative of irregular menstruation and hyperandrogenism within a 12-month period (i.e., possible PCOS) were identified. The yearly incidence and prevalence of PCOS/possible PCOS were computed per 10,000 female ADSMs, and Jonckheere-Terpstra tests for trend(s) were conducted. RESULTS:During the surveillance period, 15,059 ADSMs met the criteria for PCOS or possible PCOS (55% white, 16% Hispanic/Latina; 44% aged 22-27 years; 85% enlisted, 13% officers). The yearly incidence rate of PCOS/possible PCOS ranged from 73 per 10,000 female ADSMs in 2018 to 103 per 10,000 female ADSMs in 2022 and did not change significantly (p = .33). The prevalence of PCOS/possible PCOS increased significantly (p = .01) from 210 per 10,000 female ADSMs in 2018 to 380 per 10,000 female ADSMs in 2022. CONCLUSION:Approximately 4% of ADSMs had a diagnosis of PCOS during the 5-year surveillance period, and about 1% of ADSMs newly met criteria for PCOS each year. More research is needed to determine the health care needs of ADSMs with PCOS.

BACKGROUND AND OBJECTIVES:Insomnia is highly prevalent among military personnel, with many gaps in knowledge. The purpose of this study was to quantify the medical, psychiatric, and utilization burden of insomnia among active-duty military personnel. We hypothesized that insomnia is associated with worsened health and economic outcomes. METHODS:This was a retrospective case-control study. Data were derived from the Military Data Repository (2016-2021). Active-duty service members (ADSMs) younger than 65 years, with 12 months of continuous enrollment before and after first insomnia diagnosis and no evidence of previous insomnia or insomnia treatment, were matched 1:1 on demographic, clinical, and military characteristics to ADSMs without insomnia. Insomnia and psychiatric and medical comorbidities were defined using International Classification of Diseases, 10th Revision diagnostic codes. The impact of newly diagnosed insomnia on psychiatric and medical outcomes within 12 months was examined using time-to-event models. The impact of newly diagnosed insomnia on 12-month health care resource utilization (HCRU) was examined using generalized linear models. RESULTS:A total of 40,978 ADSMs met insomnia criteria and were matched to 40,978 ADSMs without insomnia. Participants were 78.6% male and 61.8% identified as White, with most younger than 44 years (90.3%). Insomnia was associated with increased risk of almost every studied physical and psychological health outcomes; relative to those without insomnia, ADSMs with insomnia demonstrated a 6-fold increased risk of post-traumatic stress disorder (hazard ratio [HR] 6.51, 95% CI 5.95-7.12, p < 0.001), as well as elevated risk of traumatic brain injury (HR 5.32, 95% CI 4.53-6.24, p < 0.001). ADSMs with insomnia demonstrated greater all-cause HCRU across all points of service (all p's < 0.001). DISCUSSION:Among active-duty personnel, new-onset insomnia was associated with substantially increased risk of adverse medical and psychiatric burden, as well as increased utilization, over 12 months. Key limitations include our observational study design.

Background Despite the significant health and economic burden associated with OSA among civilians, little is known about this burden among active-duty military personnel. Research Question What is the health and utilization burden of OSA among active-duty service members in the United States? Study Design and Methods Data were derived from the Military Data Repository (2016-2021). Participants included active-duty service members aged < 65 years with 12 months of continuous enrollment prior to and following a new OSA diagnosis and no evidence of prior OSA or OSA treatment. They were matched 1:1 on demographic, clinical, and military characteristics to those without OSA. OSA and medical and psychiatric comorbidities were defined based on International Classification of Diseases, 10th Revision, codes. The impact of newly diagnosed OSA on psychiatric and medical outcomes was examined by using time-to-event models. The impact on 12-month health care resource utilization was examined by using generalized linear models. Results A total of 59,203 service members with OSA were matched to 59,203 service members without OSA. Participants were 83% male and 65% White, with most < 44 years old (81%). OSA was associated with an increased risk for all physical and psychological health outcomes; relative to those without OSA, service members with OSA exhibited a fourfold increased risk for posttraumatic stress disorder (hazard ratio, 4.41; 95% CI, 4.04-4.82). In terms of utilization, OSA was associated with an additional 170,511 outpatient, 66 inpatient, and 1,852 emergency department encounters per year. Interpretation Our findings show that among US active-duty military personnel, OSA is associated with substantially increased risk for adverse physical and psychological health outcomes, as well as utilization burden over 12 months. Screening, triage, and treatment efforts could have broad impact in this population.

Purpose: This study examined the utilization of gender-affirming health care by active-duty service members during the initial 5 1/2 years that transgender and gender-diverse (TGD) individuals were authorized to serve in the U.S. military. The aim of this study was to inform policy discussions regarding inclusion of TGD individuals in the military.Methods: We conducted a retrospective cohort study using administrative health care data from the Military Data Repository (MDR). We assessed the association of demographic factors with the utilization of gender-affirming medical and surgical care. We calculated the incidence rate of initial TGD-related encounters and new prescriptions for gender-affirming hormones among Defense Department Service members between July 2016 and December 2021.Results: We identified 2481 service members with an initial health care encounter with an associated TGD-related diagnosis. More than half (53%) of these service members started gender-affirming hormones, and 14% underwent gender-affirming surgery. Mastectomies and hysterectomies accounted for more than 70% of surgeries. Service members made 3.22 initial encounters with a TGD-related diagnosis per 10,000 service members per year, with an overrepresentation of service members who were designated female in the MDR (8.62), junior enlisted (4.98), and young (4.64). Individuals designated female in the MRD comprised 17% of all service members but accounted for 46% of initial encounters, 51% of new prescriptions, and 73% of surgeries.Conclusion: The study revealed a higher-than-expected number of service members seeking gender-affirming care, particularly among service members designated female in the MDR. Military Health System clinicians provided most of this care, which may mitigate the cost of delivering this essential medical care.

Background: Beginning in July 2016, transgender service members in the US military were allowed to receive gender-affirming medical care, if so desired. Objective: This study aimed to evaluate variation in time-to-hormone therapy initiation in active duty Service members after the receipt of a diagnosis indicative of gender dysphoria in the Military Health System. Research Design: This retrospective cohort study included data from those enrolled in TRICARE Prime between July 2016 and December 2021 and extracted from the Military Health System Data Repository. Participants: A population-based sample of US Service members who had an encounter with a relevant International Classification of Diseases 9/10 diagnosis code. Measures: Time-to-gender-affirming hormone initiation after diagnosis receipt. Results: A total of 2439 Service members were included (Mage 24 y; 62% white, 16% Black; 12% Latine; 65% Junior Enlisted; 37% Army, 29% Navy, 25% Air Force, 7% Marine Corps; 46% first recorded administrative assigned gender marker female). Overall, 41% and 52% initiated gender-affirming hormone therapy within 1 and 3 years of diagnosis, respectively. In the generalized additive model, time-to-gender-affirming hormone initiation was longer for Service members with a first administrative assigned gender marker of male relative to female (P<0.001), and Asian and Pacific Islander (P=0.02) and Black (P=0.047) relative to white Service members. In time-varying interactions, junior enlisted members had longer time-to-initiation, relative to senior enlisted members and junior officers, until about 2-years postinitial diagnosis. Conclusion: The significant variation and documented inequities indicate that institutional data-driven policy modifications are needed to ensure timely access for those desiring care.

INTRODUCTION:The U.S. Military Health System (MHS) transitioned to the ICD-10-CM coding scheme in October 2015 and began the phased rollout of a new electronic health record system, MHS GENESIS, in October 2017. Both changes have the potential to affect the observed prevalence and health care utilization associated with musculoskeletal injuries (MSKIs) in service members. The purpose of this article was to (1) determine the effect of the ICD-10-CM transition on the observed prevalence of select MSKI conditions and (2) describe MSKI-related health care utilization in four MTFs during the adoption of MHS GENESIS. MATERIALS AND METHODS:We calculated monthly prevalence rates for six diagnostic groupings of MSKIs routinely seen in the MHS between October 2011 and February 2020. To determine if the transition to ICD-10-CM influenced prevalence rates, we performed an interrupted time series analysis, using the ICD-10-CM transition date (October 1, 2015) as the interruption point. To assess trends in direct and private sector care encounters during the MHS GENESIS transition, we calculated monthly MSKI-related encounters at four MTFs from November 1, 2015 through September 30, 2021. RESULTS:Three diagnoses had a significant (P < .05) change in the slope, or rate of change, for their monthly prevalence after the introduction of ICD-10-CM (patellofemoral pain syndrome, -0.18; stress fractures, 0.12; subacromial pain, 0.03). These diagnoses also had a significant level change or immediate change in monthly prevalence following the ICD-10-CM transition (patellofemoral pain syndrome, 24.2; stress fractures, 0.16; subacromial pain, 0.36). Three of the four sites adopting MHS GENESIS showed reduced 3-month averages (range: -7.1-13.0%) of MSKI-related encounters following the electronic health record transition. For two of the four MTFs, we observed an increased reliance on private sector immediately leading up to and following the change to MHS GENESIS. CONCLUSIONS:The observed differences in monthly prevalence for certain MSKIs could be because of the changes in the amount and/or specificity of available codes in ICD-10-CM. Within the six selected diagnostic groupings of MSKIs, we found that patellofemoral pain syndrome, stress fractures, and subacromial pain syndrome demonstrated the greatest changes in prevalence during the ICD-10-CM transition. Those involved in MSKI surveillance should exercise caution when evaluating MSKI prevalence that spans the ICD-10-CM transition. Changes in health care utilization patterns in two of the four MTFs during their adoption of MHS GENESIS suggest that MSKI care may have transferred from direct to private sector care during this period. Future research will be required to validate this finding and determine the impacts on clinical outcomes and military readiness.

Background: Musculoskeletal injuries (MSKIs) represent the most common, costly, and impactful medical conditions affecting active duty service members (ADSMs) of the United States Armed Forces. Inconsistent, variable MSKI surveillance methods and often incompletely described criteria for cohort selection, injuries, incidence, and prevalence have limited efforts to observe longitudinal trends, identify gaps in care, or highlight specific military branches or sites that could benefit from enhanced MSKI intervention protocols. The purpose of this manuscript is to present a comprehensive, well-documented, and reproducible framework for capturing and categorizing MSKI burden, healthcare utilization, and private sector costs for ADSMs across a 12-year period spanning the International Classification of Diseases, 10th Revision, Clinical Modification transition. Methods:This was a retrospective, longitudinal population study, including ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence and incidence rates for Upper Extremity, Lower Extremity, Spine, and Head/Neck MSKIs, associated health care utilization, and private sector costs were obtained by querying electronic health records from military treat-ment facilities, private sector care (PC) claims, and theater medical data from October 1, 2010 to September 30, 2021 (Fiscal Years 10-21), using the Military Health System Data Repository. Utilization associated with MSKIs per body region in the direct care and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC MSKI-associated costs were captured per year and categorized by service, body region, and setting. Conclusions:MSKI surveillance research in ADSMs has been impacted by variable, often incompletely described methods. While our approach is not without limitations, our aim was to present a well-documented, reproducible methodology for MSKI investigation in military personnel. By presenting a comprehensive blueprint for capturing and categorizing MSKI care in U.S. service members, our goal is for this methodology to enhance the efforts of researchers, public health officials, and Military Health System leaders to combat MSKIs, the primary medical threat to military readiness.

Abstract Introduction Sleep disorders such as insomnia and obstructive sleep apnea (OSA) are common and costly in the US Military Health System (MHS). Further, demand for sleep specialty care greatly exceeds available supply. Many MHS beneficiaries are referred off-base to the TRICARE network to access private sector care. The purpose of this study was to compare military, demographic, and clinical characteristics between MHS beneficiaries newly diagnosed with either insomnia or OSA on-base (direct care) and off-base (private sector care). Methods We identified MHS beneficiaries with a first diagnosis of insomnia or OSA between years 2016-2021 within the Military Data Repository (MDR). This large data repository includes encounter, procedure, medication, and durable medical equipment information for Active Duty personnel, dependents, National Guard, and Reserves. Demographic and military information was obtained from the MDR. Sleep disorders and medical and psychiatric comorbidities were defined based on ICD-10 diagnostic codes. Determination of direct vs private sector care was based on an indicator in the MDR. Results 235,823 MHS beneficiaries were diagnosed with either insomnia (n=143,877) or OSA (n=91,946). Of beneficiaries with insomnia, the majority (n=119,923, 83.4%) were diagnosed in direct care. Of beneficiaries with OSA, the majority (n=51,014, 55.5%) were diagnosed in private sector care. Between-groups differences (direct vs private sector care) were observed in service branch (standard mean difference [SMD]=0.46) and beneficiary category (i.e., Active Duty, dependent, National Guard, or Reserve; SMD=0.37), with most Active Duty (n=131,321, 81.6%) and dependent (n=26,987, 53.5%) beneficiaries being treated via direct care. No between-groups differences were observed in medical and psychiatric comorbidities. In terms of comorbid sleep disorders, of beneficiaries diagnosed with hypersomnia (n=12,403), the majority (n=10,055, 81.1%) were diagnosed in private sector care. Conclusion Differences in service branch and beneficiary category were observed between individuals diagnosed with insomnia or OSA in direct and private sector care. Insomnia was more likely to be diagnosed in direct care, and OSA was more likely to be diagnosed in private sector care. Future research should examine health and economic outcomes associated with direct and private sector sleep care and identify opportunities (e.g., telehealth) to bring sleep care back into the MHS. Support (if any) DoD HT94022210006.

OBJECTIVE:Despite unique experiences that may increase eating disorder risk, U.S. military service members are an understudied population. The current study examined incidence and prevalence of eating disorder diagnoses in U.S. military personnel. METHOD:This retrospective cohort study utilized Military Health System Data Repository (MDR) data on eating disorder diagnoses (2016-2021). Active duty, Reserve, and National Guard U.S. military service members who received care via TRICARE Prime insurance were identified by ICD-10 eating disorder diagnostic codes. RESULTS:During the 6-year surveillance period, 5189 Service members received incident eating disorders diagnoses, with a crude overall incidence rate of 6.2 cases per 10,000 person-years. The most common diagnosis was other/unspecified specified eating disorders, followed by binge-eating disorder, bulimia nervosa, and anorexia nervosa. There was an 18.5% overall rise in total incident cases across the surveillance period, but this trend was not statistically significant (p = 0.09). Point prevalence significantly increased across the 6-year timeframe for total eating disorders (p < 0.001). Period prevalence for 6-year surveillance period was 0.244% for total eating disorders, 0.149% for other/unspecified eating disorder, 0.043% for bulimia nervosa, 0.038% for binge-eating disorder, and 0.013% for anorexia nervosa. DISCUSSION:Overall crude incidence estimates for total eating disorders were higher than reported in prior research that included only active duty Service members and required an eating disorder diagnosis code in the first or second diagnostic position of the medical record. Comprehensive and confidential studies are needed to more thoroughly characterize the nature and scope of eating disorder symptomatology within U.S. military personnel. PUBLIC SIGNIFICANCE:U.S. military service members are a vulnerable population with regard to eating disorder symptoms. Previously reported incidence and prevalence estimates using data from the Military Health System may have been underestimated due to overly stringent case definitions. Given personal and occupational barriers (e.g., career consequences), confidential studies of military personnel may provide more complete data on the scope of eating disorders to inform screening and clinical practice guidelines for military populations.

ImportanceUse of exogenous sex steroid hormones, when indicated, may improve outcomes in adolescents and young adults with gender incongruence. Little is known about factors associated with the time from diagnosis of gender dysphoria to initiation of gender-affirming hormone therapy. Identification of inequities in time to treatment may have clinical, policy, and research implications.ObjectiveTo evaluate factors associated with time to initiation of gender-affirming hormone therapy after a diagnosis of gender dysphoria in adolescents and young adults receiving care within the US Military Health System.Design, Setting, and ParticipantsThis retrospective cohort study used TRICARE Prime billing and pharmacy data contained in the Military Health System Data Repository. Patients aged 14 to 22 years, excluding service members and their spouses, who received a diagnosis of gender dysphoria between September 1, 2016, and December 31, 2021, were included. The data were analyzed between August 30 and October 12, 2023.ExposuresIncluded patient characteristics were race and ethnicity, age group, first sex assigned in the medical record, and TRICARE Prime sponsor military rank and service at the time of diagnosis. Health care and contextual characteristics included the year of diagnosis and the primary system in which the patient received health care.Main Outcomes and MeasuresThe primary outcome was the time between initial diagnosis of gender dysphoria to the first prescription for gender-affirming hormone medication within a 2-year period. A Poisson generalized additive model was used to evaluate this primary outcome. Adjusted probability estimates were calculated per specified reference categories.ResultsOf the 3066 patients included (median [IQR] age, 17 [15-19] years; 2259 with first assigned gender marker of female [74%]), an unadjusted survival model accounting for censoring indicated that 37% (95% CI, 35%-39%) initiated therapy by 2 years. Age-adjusted curves indicated that the proportion initiating therapy by 2 years increased by age category (aged 14-16 years, 25%; aged 17-18 years, 39%; aged 19-22 years, 55%). Incidence rate ratios (IRRs) and 2-year adjusted probabilities indicated that longer times to hormone initiation were experienced by adolescents aged 14 to 16 years (IRR, 0.36; 95% CI, 0.30-0.44) and 17 to 18 years (IRR, 0.66; 95% CI, 0.54-0.79) compared with young adults aged 19 to 22 years and Black compared with White adolescents (IRR, 0.73; 95% CI, 0.54-0.99). Senior officer compared with junior enlisted insurance sponsor rank (IRR, 1.93; 95% CI, 1.04-3.55) and civilian compared with military health care setting (IRR, 1.21; 95% CI, 1.02-1.43) was associated with shorter time to hormone initiation.Conclusions and RelevanceIn this cohort study, most adolescents and young adults with a diagnosis of gender dysphoria receiving health care through the US military did not initiate exogenous sex steroid hormone therapy within 2 years of diagnosis. Inequities in time to treatment indicate the need to identify and reduce barriers to care.