Tracey Pérez Koehlmoos

Introduction: Paid parental leave has demonstrated clear benefits for the health and well-being of infants and families. In 2022, the amount of paternity leave available to US servicemen increased from 3 to 12 weeks. Although family wellbeing positively impacts readiness for the military mission, extra time away negatively impacts readiness. In 2019, unintended pregnancy (UIP) contributed significantly to lost readiness among active duty servicewomen. Given this recent policy change, we estimated lost readiness days due to parental leave in active duty servicemen. Materials and Methods: We conducted a cross-sectional study of UIP and readiness days lost because of parental leave among active duty servicemen between FY 2022-2025. Servicemen were identified by matching them to confirmed deliveries or if an infant child was added as a dependent to their beneficiary record. UIP estimates were calculated as 5.5% (military expected prevalence) and 41.7% (civilian expected prevalence) of all new fathers. Maximum (84 days per birth) and partial (52 days per birth; median leave days taken in the Army) readiness days lost were calculated among all new fathers and from UIP estimates. Results: We identified 280,498 total incidences of new fathers among 226,360 active duty servicemen and estimated 23,561,832 maximum readiness days lost (mRDL) and 15,427,390 partial readiness days lost (pRDL). Using the military expected prevalence (5.5%), we estimated 15,427 UIP with an expected 1,295,901 mRDL and 848,506 pRDL due to UIP. Using the civilian expected prevalence (41.7%), we estimated 116,968 UIP with an expected 9,825,284 mRDL and 6,082,319 pRDL due to UIP. Groups with the highest estimates of UIP, mRDL, and pRDL include active duty members in senior enlisted ranks, the US Army, and in warfighter/combat specialties. Conclusions: This is the first study to examine the impact of parental leave on readiness among active duty servicemen. Our findings show that similar to servicewomen, UIP results in a considerable number of lost readiness days among servicemen. Efforts to reduce UIP through expanding reproductive health services targeted to men could reduce the number of readiness days lost among active duty servicemen.

Introduction: In 2017, the United States Marine Corps (USMC) increased the pull-up requirements of the Physical Fitness Test (PFT) to improve combat readiness, raising concerns regarding potential increases in upper extremity (UE) musculoskeletal injuries (MSKIs). This study assesses the impact of this policy change on UE MSKI incidence among active-duty male Marines. Materials and Methods: Linear regressions estimated with ordinary least squares were used to perform interrupted time series analyses of UE MSKI rates among male Marines from the Military Health System Data Repository between 2014 and 2023. Upper extremity MSKI rate trends were evaluated pre- (2014-2016) and post-intervention (2017-2023), stratified by age, race/ethnicity, body mass index (BMI), and rank. Newey-West SEs were used in linear regression analyses to adjust for violations from autocorrelation and heteroskedasticity. Results: The study population included 231,323 Marines in the pre-intervention period (2014-2016) and 313,537 in the post-intervention period (2017-2023). Cumulative UE MSKI proportions increased (9.0%-9.4%). Pre-policy, UE MSKI rates trended downward (b1 = −5.09, P < .001). Post-policy, this trend significantly reversed (b3 = 5.11, P < .001) but not immediately (b2 = −4.00, P = .431). Subgroup analysis revealed sustained increasing rates among Marines <20 years (b1 + b3 = 0.88, P < .001). Conversely, decreasing rates occurred in Marines with obesity (b1 + b3 = −1.09, P = .006), ages 40-49 (b1 + b3 = −1.21, P = .046), and senior enlisted (b1 + b3 = −1.10, P = .012). Warrant officers experienced a significant decrease in UE MSKI rates (b2 = −34.22, P = .007) as well as subsequent trend stabilization (b3 = 6.23, P < .001). Conclusions: The 2017 standards were temporally associated with a plateau in previously declining UE MSKI rates. While no immediate population-level spike occurred, the heterogeneity of subgroup responses highlights specific risks for younger personnel. Future policy modifications should balance fitness objectives with targeted injury prevention strategies to optimize readiness.

Introduction: In 2016, all military occupational specialties in the United States Marine Corps (USMC) were opened to women, including ground combat roles. Limited service-specific data exist regarding musculoskeletal injury (MSKI) and behavioral health (BH) outcomes among female Marines. This study evaluates the prevalence and risk of MSKI and BH diagnoses among female Marines in ground combat specialties (GCSs) compared with non-ground combat specialties (NGCSs). Materials and Methods: We conducted a retrospective cross-sectional analysis of all active duty female Marines from 2016 to 2023 using Military Health System data. MSKI and BH diagnoses were identified using International Classification of Diseases, Tenth Revision (ICD-10) codes. Women with pregnancy-related diagnoses during or within 12 months before the study period were excluded. Multivariable logistic regression models were used to assess associations between occupational specialty and MSKI or BH diagnoses, adjusting for age, race and ethnicity, rank, body mass index, tobacco use, and alcohol/substance use. Results: A total of 30,280 active duty female Marines were identified for inclusion between January 2016 to December 2023; of whom 218 (0.7%) were in the GCS. The majority of females in the GCS were between the ages of 18-23 (58.7%), of White race (70.6%), and in an enlisted rank (78.9%). The prevalence of women in a GCS increased over the study period, from 16.9 per 1,000 in 2016 to 21.5 per 1,000 in 2023. Female Marines in GCS had no significant odds of MSKI diagnosis (OR = 1.09, 95% CI, = 0.80-1.49) or BH disorder (OR = 0.96, 95% CI, = 0.70-1.30) when compared to those in a non-GCS. Conclusions: Among active duty female Marines, assignment to a GCS was not associated with increased risk of MSKI or BH diagnoses. Despite occupational integration, the overall burden of MSKI and BH conditions remains substantial, underscoring the need for continued surveillance and targeted prevention strategies.

Objective: Conservatively quantify the public health and economic damages of low-quality generic drugs on chronic disease management in the United States based on available studies, and review health system solutions to avoid low-quality and incentivize high-quality generics. Data Sources: Generic drug quality is an evolving but sparse field of research; therefore, the expertise of 21 experts with experience in the field were relied upon to identify meaningful areas of existing research within chronic disease, where medication issues are expected to be most pronounced due to longevity and persistence of treatment. Four diseases (epilepsy, multiple sclerosis, atherosclerosis, and hypertension) were chosen by the group due to the relative abundance of informative studies and the diversity of the diseases. A chronological review of published health system solutions was also performed. Data Synthesis / Results: Extrapolating from studies in these four chronic diseases and focusing on the most directly observable 10% low-quality generic drugs, we conservatively estimate the 2024 economic burden of this low-quality subset of generic drugs at $18.4 billion growing to $238 billion over the next 10 years if not addressed, largely due to many thousands of avoidable serious adverse events like disease relapse and hospitalizations. Potential solutions are discussed that may enable a market correction to avoid the low-quality generic drugs and incentivize continuous product improvement. Conclusion and Relevance: This novel review represents the first broad population analysis of the substantial economic and public health impact from low-quality generic drugs and synthesizes modern approaches to addressing this largely underappreciated issue. Real-world approaches are reviewed where pharmacy practice can be modified to help ensure only the highest-quality generics are dispensed to patients to improve outcomes and reduce waste.

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Objectives: Premature and early menopause are public health issues that increase the risk for chronic conditions, including cardiovascular disease and osteoporosis. We aimed to estimate the average age at menopause and identify factors associated with age at menopause in a nationally representative sample of American women. Methods: We used a population-based cross-sectional study to investigate menopause timing in 15,322 women aged 15 years and older from the 2013 to 2023 National Health and Nutrition Examination Survey (NHANES). The outcomes were age at natural and surgical menopause (time-to-events) and menopause onset as multinomial categories (premature, early, typical, late). Results: Life tables demonstrated a median age of natural menopause at 50 years, while survey-adjusted estimates suggested a weighted mean age of 49.5 years (95% confidence interval: 49.2-49.8). The prevalence estimates of premature and early natural menopause in postmenopausal women were 4.6% and 10.0%, respectively. Multivariate Cox proportional hazard models identified less education, smoking, and mild depression as factors associated with younger natural menopause onset, whereas obesity, high blood pressure, high cholesterol, and arthritis were significantly associated with younger age at surgical menopause. In postmenopausal women, less education, little sleep, diabetes, and mild depression demonstrated associations with increased odds for premature natural menopause. Conclusions: Differences between calculated associations and menopause timing reported in the literature are likely due to methodological and participant inclusion differences. The life table method demonstrates a similar estimate to the commonly reported value for natural menopause onset. Several modifiable factors may provide opportunities for intervention.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic led to well-documented surges in psychological distress. Although trends in emergency department (ED) utilization for mental health (MH) needs were studied in the civilian sector during the pandemic’s early stages, research on later stages and within the Military Health System (MHS) is limited. This study aimed to examine trends in MH-related ED visits and subsequent inpatient admissions among TRICARE beneficiaries throughout the pandemic. Materials and Methods: This retrospective cross-sectional study analyzed administrative healthcare data from the Military Health System Data Repository (MDR) for TRICARE beneficiaries aged 3 and older. Associations between demographic characteristics of MH-related ED visits and subsequent inpatient admissions were compared across 3 periods: pre-pandemic (January 1, 2019-March 10, 2020), acute pandemic (March 11, 2020-July 31, 2021), and post-acute pandemic (August 1, 2021-December 31, 2022). Multivariable logistic regression analyses and generalized estimating equations (GEEs) were used to calculate odds for MH-related ED visits, subsequent inpatient admissions, and associated diagnosis categories, adjusting for sex, age, race, and sponsor’s military rank. This study was declared exempt by the Institutional Review Board of the Uniformed Services University of the Health Sciences. Results: The study included 153,346 MH-related ED encounters for 124,053 unique patients. Compared to the pre-pandemic period, the odds of an ED visit being MH-related were higher in the acute period (OR: 1.18, 95% CI: 1.05-1.28) but lower in the post-acute period (OR: 0.87, 95% CI: 0.85-0.94). The odds of a subsequent inpatient admission following an MH-related ED visit were significantly higher during both the acute (OR: 1.46, 95% CI: 1.41-1.52) and post-acute periods (OR: 1.37, 95% CI: 1.33-1.41) compared to the pre-pandemic period. Significant changes in the odds of some MH-related diagnosis categories (relative to absence of specified MH-related diagnosis categories) associated with the MH-related ED visit and inpatient admissions were found in the acute and post-acute comparisons to the pre-pandemic period. Conclusions: The MHS experienced a significant increase in the acuity of MH-related ED presentations, evidenced by higher odds of inpatient admissions throughout the pandemic. However, the overall odds of ED visits for MH concerns decreased in the later pandemic stage, potentially reflecting changes in care pathways. These findings highlight the sustained impact of the pandemic on acute MH needs within the military community and underscore the importance of continued monitoring and resource allocation to support beneficiary well-being and military readiness.

Introduction: Historically, women in the U.S. Military have been prohibited from serving in ground combat occupational specialties (GCS) until the Secretary of Defense lifted the exclusion in January 2016, prompting studies into health outcomes for this new cohort. Phillips et al.(2016-2019) found that active duty servicewomen (ADSW) in GCS had lower odds of musculoskeletal injury (MSKI) and behavioral health (BH) diagnoses than peers in non-ground combat specialties (NGCS), likely because of a “healthy warrior” selection effect. With continued integration, cohort maturation, and factors such as the COVID-19 pandemic, this study updates MSKI and BH trends among ADSW from 2020 to 2023 and compares findings with the earlier cohort. Materials and Methods: This retrospective cross-sectional study used data from the Military Health System Data Repository (MDR), including all ADSW (n = 77,568) who served from January 1, 2020, to December 31, 2023. Women in the Guard, Reserve, or with pregnancy diagnoses during or in the year prior were excluded. Primary outcomes—MSKI and BH diagnoses—were identified via ICD-10 codes. Adjusted odds ratios (AORs) and 95% CIs were calculated using multivariable logistic regression, comparing GCS vs. NGCS ADSW while adjusting for age, race & ethnicity, rank, and BMI. Two-sample z-tests assessed differences from Phillips et al.s 2016 to 2019 estimates. This study received an exempt determination from the Institutional Review Board at the Uniformed Services University of the Health Sciences. Results: Of 77,568 ADSW, 5,024 (6.5%) served in GCS. Compared to NGCS, GCS women were younger (72.1% vs. 47.0% aged 18-23), more often enlisted (68.4% vs. 57.0%), and had lower obesity rates (8.4% vs. 12.6%), but higher rates of tobacco (7.7% vs. 7.6%), alcohol (7.9% vs. 6.7%), and substance use (2.5% vs. 1.9%). Adjusted analyses showed higher MSKI odds in GCS (AOR = 1.21, 95% CI: 1.13-1.30), a significant reversal from Phillips et al.(AOR = 0.86, 95% CI: 0.79-0.93; z = 6.01, P < .001). BH odds were lower in GCS (AOR = 0.83, 95% CI: 0.78-0.89), consistent with earlier findings (Phillips AOR = 0.87; 95% CI: 0.80-0.95). Conclusions: The increase in MSKI odds for GCS women contrasts sharply with prior findings, suggesting the dissipation of the initial selection effect as more women enter and remain in combat roles. This shift may reflect greater exposure duration, cumulative physical demands, or pandemic-era fitness disruptions. The continued lower BH odds in GCS, despite higher substance use, may reflect resilience, unit cohesion, or underreporting tied to stigma. These findings highlight the need for targeted, female-specific injury prevention and confidential, destigmatized mental health support as the Army moves toward sex-neutral standards in combat fitness.

Introduction: In November 2012, the U.S. Marine Corps announced a policy change to the female Physical Fitness Test (PFT), replacing the flexed arm hang with pull-ups. This change, which became effective on January 1, 2017, aimed to standardize fitness requirements and facilitate gender integration into combat roles. Musculoskeletal injuries (MSKIs) are a leading cause of medical encounters and non-deployability among service members. Upper extremity (UE) injuries are particularly relevant given the physical demands of pull-ups. Materials and Methods: A retrospective open cohort study was conducted using data from the Military Health System Data Repository (MDR) from fiscal years 2010-2023. International Classification of Diseases (ICD)-9 and ICD-10 codes identified UE injuries in female Marines. Single and multigroup interrupted time series analyses were used to assess changes in injury rates surrounding the PFT policy change. Results: A total of 49,910 female Marines were included in this study, of whom 6,125 (12.3%) had at least one UE MSKI. The overall trend of UE MSKIs decreased both before and after the PFT policy change. The immediate change post-policy showed no significant changes in UE MSKIs at the time of intervention. However, specific groups experienced significant decreases in MSKI rates at the intervention: Marines ages 20-29 years, those of Black race, junior enlisted ranks, and those with overweight body mass index. Conclusion: The findings highlight positive impacts of the PFT policy change on reducing MSKI rates among specific subgroups of female Marines. These results inform future policy adjustments aimed at mitigating injury risks while promoting operational readiness across diverse demographics.