Trends in Surgical Volume and Outcomes and Workforce Availability in a Health System in Transition, 2016-2023

In 2016, Congress enacted several reforms to restructure the Military Health System (MHS) and transition operational control of military treatment facilities (MTFs) from the individual services to the Defense Health Agency. Prognostications suggested that reducing MTF access as a result of these reforms would have negative repercussions on quality of care and patient safety. We sought to evaluate changes in the volume of surgical procedures in an integrated healthcare region, with a secondary objective of evaluating the impact of staffing on procedural volume and outcomes.

We performed a retrospective cohort study of administrative and claims data in the MHS Data Repository, querying claims data for MHS beneficiaries aged 18 to 64 years who received care in any medical facility in the National Capital Region from October 1, 2015 to September 30, 2023. The primary outcome was the number of surgical procedures performed during the study period in MTFs and in private sector care. We also queried total and military-specific staffing assignments among different providers. All-cause 90-day hospital readmissions were evaluated as a healthcare quality metric. Trend analyses were conducted to assess changes in surgical volume and hospital readmissions, with additional analyses restricted to major DoD facilities in the region.

We identified 39,724 surgical procedures performed during the study period, with 20,593 in MTFs and 19,131 in the civilian sector. There was an overall decline in surgical volume at DoD facilities. Ninety-day readmissions declined between 2016 and 2019 but increased from 2020 to 2023. Readmissions in the civilian sector increased from 2016 to 2018, followed by a decline between 2020 and 2022 and an uptick in 2023. We observed declines in staffing across all provider types at MTFs.

The decline in surgical procedures and corresponding reduction in staffing at MTFs reflects shifts in beneficiary care to the civilian health sector as a result of the restructuring of the MHS and limited capacity within direct care facilities during the pandemic. The MHS should determine which services should be delivered in direct care, staff to those requirements, and re-attract patients to maintain the readiness of the provider workforce.