Once a year, the healthcare leadership of all branches of our military services come together to learn, network, and interact with its vendors and suppliers. The conference provides an opportunity to discuss issues and problems, share potential solutions and best practices, affirm the mission, and gain clarity and plan for the Military Health System’s (MHS) vision and direction for the future. Army, Navy, Air Force, Marines, and Coast Guard were all represented.

We found the many service members who stopped by our booth to be very interested in the value of evidence-based medicine. We are pleased to have had the opportunity to hear first hand from the military about their experiences, challenges, and commitment to provide world-class care to their patients.

We did notice that change was in the air! A number of themes dominated this year’s conference, which will impact the future of the MHS.

• Health versus healthcare. We noted an increased focus on improving health outcomes for military personnel and their families in ways that support the need for “readiness” while recognizing our obligation to those who serve, often in harm’s way!
• Leaner. As we move from wars on two fronts to peace, a leaner military will also include a reduction in military health personnel on active duty. This will require remaining providers to work smarter, more efficiently, and without unnecessary redundancy.
• Integration and merging of healthcare delivery across the different branches of the military. The new Walter Reed medical complex was described as an example of this “integration” philosophy.
• Innovation and patient-focused care. We were pleased to see a willingness to deliver healthcare in new ways and settings using new technologies and people, all toward the benefit of our military personnel and their families, including our wounded warriors. For example, physical therapists may treat musculoskeletal injuries rather than a family practitioner.
• Achieving significant cost reductions and enhancing cost-effectiveness/return on investment. The military budget will be reduced by one quarter trillion dollars over the next 5 years. So the message—world class healthcare BUT not at any cost!
• Incorporation of evidence. We found a commitment to use scientific research and evidence-based medicine throughout the MHS as the basis for improving the safety and effectiveness of care and the quality of healthcare decision making. In addition, major advances in trauma management, including survival and return to productive lives, were discussed. Did you know that nearly 90% of those wounded in Iraq and Afghanistan have survived their injuries, compared with 70% in WWII and nearly 76% in Korea and Vietnam?

The overriding take-home message is this: Major changes will occur and must occur! BUT, in spite of the constraints the MHS must deal with, the commitment to provide healthcare that results in meaningful and necessary advances in health must be met. The nation’s armed forces must be “ready,” and this clearly includes healthy armed forces and their families. Those who support the MHS must stand ready to deliver on the services that will help to achieve these goals.

Osteoporosis and heart failure are common, chronic, and costly conditions that share common etiologic factors such as older age, postmenopausal status, and diabetes. Previous studies have suggested that heart failure may predispose a patient to fractures not only because it increases the incidence of falling, but because both heart failure itself and its medical treatments can lead to loss of bone mass.

The researchers conducted a population cohort study consisting of 45,509 adults undergoing bone mineral density testing for the first time and followed them for up to 10 years. Of 45,509 adults included in the study, 1841 had recent-onset heart failure. After adjusting for traditional osteoporosis risk factors, the researchers found that heart failure was associated with a 30% increase in major fractures.

The authors believe that screening for osteoporosis should include a review of chest x-rays for patients with heart failure. These patients tend to undergo many x-rays that often, incidentally, show many fractures of the spine that could provide an indication of severe osteoporosis and need for treatment.

1. Majumdar S, Ezekowitz JA, Lix LM, Leslie L. Heart failure is a clinically and densitometrically independent risk factor for osteoporotic fractures: population-based cohort study of 45,509 subjects. J Clin Endocrinal Metab. 2012. Epub ahead of print. January 18, 2012. Abstract available at: http://jcem.endojournals.org/content/early/2012/01/12/jc.2011-3055.abstract?sid=2c1ac1c3-1fc5-4f25-abd9-cedb116f1c04. Accessed February 3, 2012.

Vismodegib is the first drug approved for metastatic basal cell carcinoma and was reviewed under the agency’s priority review program, which provides for an expedited 6-month review of drugs that may offer major advances in treatment. The drug is being approved ahead of the March 8, 2012, prescription user fee goal date.

Vismodegib is an oral medication taken once daily and works by inhibiting the Hedgehog pathway, a pathway that is active in most basal cell cancers and only a few normal tissues, such as hair follicles. The safety and effectiveness were evaluated in a single, multicenter clinical study in 96 patients with locally advanced or metastatic basal cell carcinoma. The clinical study’s primary endpoint was objective response rate (ORR) or the percentage of patients who experienced complete and partial shrinkage or disappearance of the cancerous lesions after treatment. Of the patients with metastatic disease who received vismodegib, 30% experienced a partial response and 43% of patients with locally advanced disease experienced a complete or partial response.

The most common side effects were muscle spasms, hair loss, weight loss, nausea, diarrhea, fatigue, distorted sense of taste, decreased appetite, constipation, vomiting, and loss of taste function in the tongue.

Vismodegib was approved with a “black box” warning alerting patients and healthcare professionals of the potential risk of death or severe birth defects. Pregnancy status must be verified prior to the start of treatment and both male and female patients should be warned about these risks and the need for birth control.

To read more about vismodegib from Hayes Technology Prognosis Click here.

1. Food and Drug Administration (FDA). News & Events. FDA News Release. January 30, 2012. FDA approves new treatment for most common type of skin cancer. Available at:
   http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm289545.htm. Accessed February 2, 2012.

In nursing school, our instructors drilled us about the 5 patient rights for medication administration as applied to patient safety. The “5Rs,” as they are known, can be summarized as the following:

• Right dose
• Right time
• Right patient
• Right route
• Right drug

Although these basics remain important in terms of patient safety, as healthcare reform moves us toward more collaborative, patient-centered care, isn’t it time to delineate the rights of hospitals and providers?

Provisions in the Patient Protection and Affordable Care Act (PPACA) will require hospitals to consider patient outcomes when evaluating and acquiring health technologies. Improving patient outcomes, however, depends on the application of evidence-based healthcare. If we are to elevate healthcare quality, improve the health of our population, and reduce healthcare costs, hospitals must have the commitment and tools to enable them to do so. In my opinion, the 5 rights of hospitals and providers necessary to make the right choice with regard to technology acquisition decisions include:

• Right information: Timely access to unbiased evidence that clearly shows whether a medical technology works and is safe, how well it compares to other approaches, and when and for whom it should be used.
• Right transparency: Full and candid disclosure and discussion of all stakeholders’ biases and conflicts of interest, such as physicians receiving royalty payments and consulting fees from manufacturers or pharmaceutical companies, and higher professional fees associated with providing the “new” or “enhanced” procedure.
• Right commitment: Alignment from all decision makers and service providers to integrate the best available evidence into all models of patient care.
• Right process: An evidence-based decision-making process for technology acquisition that avoids the adoption of “unproven” new technologies that add substantial costs to our healthcare system without delivering measurable improvements in patient outcomes or operational efficiencies.
• Right financial forecasting: Understanding the reimbursement landscape for new technologies so there are no surprises when it comes to reimbursement for services.

In 2010, a total of 28,664 organ transplants were performed in the U.S., including 16,899 kidney, 6291 liver, 2333 heart, and 1770 lung transplants. Previous studies have been unable to accurately estimate the risk of both common and rarer cancers among this population.

The research team linked data from the U.S. registry of transplant recipients from 1987 through 2008 with 13 U.S. cancer registries. They observed a twofold overall increased risk of cancer among all U.S. transplant recipients. They also noted elevated risk for 32 different types of cancer, some known to be related to infectious agents (e.g., anal cancer, Kaposi sarcoma) and others unrelated to infections (e.g., melanoma, thyroid cancer).

The most common cancers among transplant recipients were non-Hodgkin’s lymphoma (14.1%), lung cancer (12.6%), liver cancer (8.7%), and kidney cancer (7.1%). The authors carried out additional analyses of these four cancers and, based on known risk and their new study, report the following:

• Non-Hodgkin’s lymphoma is elevated more than sevenfold in transplant recipients, with non-Hodgkin’s lymphoma incidence highest among those who received transplants as children or older adults. Non-Hodgkin’s lymphoma incidence was highest in lung recipients, intermediate in liver and heart recipients, and lowest in kidney recipients.
• Lung cancer risk was highest in lung recipients, with smoking-related disease often the reason for the transplant. The studies of cancer show that among lung recipients, most of whom received a single lung transplant, lung cancer typically arises in the recipient’s remaining diseased lung rather than the transplanted one. The increased risk for lung cancer may also be related to inflammation or chronic lung infections.
• The risk of liver cancer was elevated only among liver recipients, which can be attributed in part to recurrent hepatitis B or C infection in the transplanted liver.
• The risk of kidney cancer is increased for all kidney recipients, due in part to the presence of multiple kidney cysts, which can become cancerous. However, an elevated risk was also observed among recipients of other organs. Therefore, the researchers suggest that the risk for kidney cancer could be partly due to exposure to immune-suppressive medications, which may have direct carcinogenic effects.

1. Engels EA, Pfeiffer RM, Fraumeni JF, et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA. 2011;306(17):1891-901. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/22045767. Accessed February 1, 2012.

In 2010, breast cancer screening rates were 72.4%, below the Healthy People 2020 target of 81%; cervical cancer screening was 83%, below the target of 93%; and colorectal cancer screening was 58.6%, below the target of 70.5%.

The screening rates for all three cancers were significantly lower among Asians compared with other groups, the study found. Hispanics were less likely to be screened for cervical and colorectal cancer when compared with non-Hispanics.

To assess the use of currently recommended cancer screening tests by age, race, ethnicity, education, length of residence in the United States, and the source and financing of healthcare, researchers analyzed data from the 2010 National Health Interview Survey, which tracks progress toward the achievement of Healthy People 2020 objectives.

Significant findings include:

• Screening rates for breast cancer remained relatively stable and varied no more than 3% over the period 2000 to 2010.
• From 2000 to 2010, colorectal cancer screening rates increased markedly for men and women, with the rate for women increasing slightly faster so that rates among both sexes were nearly identical (58.5% for men and 58.8% for women) in 2010.
• From 2000 to 2010, a small but statistically significant downward trend of 3.3% was observed in the rate of women who reported getting a Pap test within the last 3 years.
• Considerably lower breast, cervical, and colorectal cancer screening use was reported by those without any usual source of healthcare or health insurance.

The authors note that this study reinforces the need to identify and track cancer screening disparities. Additionally, the report provides guidance for the development programs to increase the use of screening tests in order to meet Healthy People 2020 targets and simultaneously reduce cancer morbidity and mortality.

According to the authors, the Affordable Care Act is expected to reduce financial barriers to care by expanding insurance coverage. Other efforts are needed such as developing systems that identify individuals eligible for cancer screening tests, actively encouraging the use of screening tests, and monitoring participation to improve screening rates.

1. Klabunde CN, Brown M, Ballard-Barbash R, et al.; Centers for Disease Control and Prevention. Cancer Screening United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61(03)41-45. Available at:
   http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6103a1.htm?s_cid=mm6103a1_w. Accessed January 30, 2012.

If you’re attending the 2012 Military Health System (MHS) Conference on January 30 to February 2, 2012, stop by and visit us at Booth #424. We’ll be sharing our expertise and capabilities to support evidence-based, patient-centered initiatives that concentrate on ways to best serve the preventive and healthcare needs of the diverse beneficiary population served by the MHS.

As a TRICARE Management Activity (TMA) contractor since 1997, we are proud to provide information to meet the ever-increasing need for unbiased healthcare research that will improve healthcare delivery, enhance value, and optimize health outcomes for those who serve our country and their dependents.

See you at the Gaylord National Hotel and Convention Center in Maryland!

The updated evidence review from AHRQ’s Effective Health Care Program, Comparative Effectiveness of Second Generation Antidepressants in the Pharmacologic Treatment of Adult Depression—An Update to a 2007 Report, reviews the evidence on 13 second-generation antidepressants—bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxine.

The report updates current evidence on the comparative efficacy, benefits, and harms of second-generation therapies in treating patients with major depressive disorder, dysthymia, and subsyndromal depression. It also highlights areas for future research, including the need for research on the efficacy of second-generation antidepressants in populations with accompanying symptoms such as anxiety, insomnia, pain, or fatigue and in patients who have not responded to initial treatments. Likewise, future research should clarify the differences of second-generation antidepressants in subgroups based on age, sex, race, or ethnicity, and common comorbidities.

Finally, no evidence in this report addresses how second-generation antidepressants compare when a patient responds to one agent and then is required to switch to a different agent (e.g., because of changes in insurance benefit). Because these circumstances may be relevant for many patients, future studies should consider this question.

1. Gartlehner G, Hansen RA, Morgan LC, et al. Comparative Effectiveness of Second Generation Antidepressants in the Pharmacologic Treatment of Adult Depression: An Update of the 2007 Comparative Effectiveness Review. Comparative Effectiveness Review No. 46 (Prepared by the RTI InternationalUniversity of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality. December 2011. AHRQ Publication No. 12-EHC012-EF. Available at: http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=862. Accessed January 26, 2012.

Lansdale, PA — January 26, 2012 – Hayes, Inc., a research and consulting firm that specializes in the evaluation of health technologies, is pleased to announce that it will be an exhibitor at the 2012 Military Health System (MHS) Conference to be held from January 30 to February 2, 2012, at the Gaylord National Hotel and Convention Center at National Harbor, MD. An estimated 4000 military and civilian medical personnel from the MHS are expected to attend. Hayes will share information about its capabilities with guests at Booth #424.

“Our products and services support sound, evidence-based decision making, effective use of precious medical resources, and better quality of care for patients,” states Cici Collins, Vice President of Government Services at Hayes, Inc. “As a TRICARE Management Activity (TMA) contractor since 1997, Hayes is proud to provide information to meet the ever increasing need for unbiased healthcare research that will improve healthcare delivery, enhance value, and optimize health outcomes for those who serve our country and their dependents.”

The 2012 MHS Conference, which is designed to enhance partnerships within and outside the federal sector, will give Hayes an opportunity to share its expertise and capabilities to support evidence-based, patient-centered initiatives that concentrate on ways to best serve the preventive and healthcare needs of the diverse beneficiary population served by the MHS.

Hayes, Inc., an internationally recognized leader in health technology research and consulting, is dedicated to the delivery of high-quality healthcare and improved outcomes through the integration of evidence into decision making and policy development. The unbiased information and comparative-effectiveness analyses we provide enable evidence-based decisions about acquiring, managing, and paying for health technologies. Our worldwide clients include hospitals, healthcare systems, government agencies, health plans, and employers. Hayes, Inc. is a certified woman-owned small business (WOSB).

For more information about Hayes, Inc., visit www.hayesinc.com. Or, contact Hayes, Inc. by mail at 157 S. Broad Street, Lansdale, PA 19446; by telephone at 215.855.0615; by email hayesinfo@hayesinc.com; or by fax at 215.855.5218.

The researchers analyzed data from the National Hospital Discharge Survey on non–traumatic lower–limb amputations and from the National Health Interview Survey on the prevalence of diagnosed diabetes from 1988 to 2008. The researchers found that the decrease in lower–limb amputation rates was greater among people with diagnosed diabetes compared with those without diabetes. However, the rate in 2008 was still approximately 8 times higher among people with diagnosed diabetes compared with those without it.

The age–adjusted rate of nontraumatic lower–limb amputations was 3.9 per 1000 people with diagnosed diabetes in 2008 compared with 11.2 per 1000 in 1996. Non–traumatic lower–limb amputations refer to those caused by circulatory problems that are a common complication among people with diabetes rather than amputations caused by injuries.

The study also found that, among people with diagnosed diabetes in 2008, men had higher age–adjusted rates of leg and foot amputations than women (6 per 1000 versus 1.9), and blacks had higher rates than whites (4.9 per 1000 versus 2.9). Adults aged 75 years and older had the highest rate—6.2 per 1000—compared with other age groups.

The study authors note that improvements in blood sugar control, foot care, and diabetes management, along with declines in cardiovascular disease, are likely to have contributed to the decline in leg and foot amputations among people with diagnosed diabetes.

In addition to being the leading cause of nontraumatic lower–limb amputations, diabetes is the leading cause of kidney failure and new cases of blindness among adults, and the seventh leading cause of death in the United States. People with diabetes are at increased risk of other complications such as heart attacks, strokes, and high blood pressure.

1. Li Yanfeng, Burrows NR, Gregg EW, Albright A, Geiss LS. Declining rates of hospitalization for nontraumatic lower-extremity amputation in the diabetic population aged 40 years or older: U.S., 1988-2008. Diabetes Care. 2012;35(2):273-277. Abstract available at: http://care.diabetesjournals.org/content/35/2/273.abstract. Accessed January 25, 2012.