Study Attacks Health Care in Air Force

U.S. Air Force hospitals--including six of eight in California--have much worse complication rates than civilian medical centers in obstetrics and gynecology cases, a Defense Department study concludes, adding to concern that armed forces medicine in general has pervasive and stubborn problems with women’s health.

Women giving birth in Air Force hospitals suffered lacerations to the cervix twice as often as women in civilian centers, the report says. The rates of some lacerations during birth to the area around the vagina were more than double the civilian rate and women delivering in Air Force facilities were significantly more likely than civilians to have initial serious symptoms of toxemia of pregnancy and postpartum hemorrhage.

Suspicion May Be at Root

Moreover, Air Force data suggest that for some other conditions--most notably ruptured appendix--military personnel and dependents suffer unnecessarily because they are not treated promptly. The president of the consulting firm that did the study speculated that the problem may have its roots in suspicion among military commanders and supervisors that many medical complaints come from malingerers. (In such cases, patients are discouraged from seeking care because it is believed they are faking.)

The Air Force, however, discounts every deficiency discovered in the study by Health Data Institute Inc. of Newton, Mass., the civilian contractor. And the Defense Department says there is no evidence that women get far worse care in Air Force facilities than in civilian hospitals.

“There was only one valid criticism: That the paper work (in the Air Force hospitals) was lousy,” said Col. Robert A. Buethe, director of medical plans and resources for the Air Force. Buethe, an obstetrician-gynecologist, said the report’s finding resulted from poor record keeping rather than inadequate medical care.

Dr. Paul Gertman, president of the consulting company, however, vigorously defends the work performed under a contract under which the company would have first analyzed Air Force women’s health care, then that of the Army and Navy in subsequent studies. The report surfaced earlier this year when preliminary copies of it were leaked by Pentagon sources.

The Health Data Institute contract abruptly was canceled by Defense Department officials--apparently in part, Gertman said, because of uneasiness within the services with review of quality of care by civilian outsiders and perhaps also because of the stark contrast Health Data Institute identified between military and civilian care.

The Air Force and the Defense Department said the criticisms of women’s health care made by Health Data Institute were dismissed as without merit after a longtime Air Force consultant could not verify them after a review of records he inspected at a hospital.

Nonetheless, the findings that Air Force hospitals have poor records in obstetrics and gynecology cases were in apparent concert with evidence uncovered in a 4-month inquiry by The Times that focused on quality of care and malpractice at three Southern California Navy hospitals--Long Beach, Camp Pendleton and San Diego. In stories published Sunday, top Navy officials conceded women’s health care has been an especially trouble-plagued field.

Focus of Study

Obstetrics-gynecology was chosen for emphasis in the Air Force research, Gertman said, because many in-hospital complications common to its practice offer the researcher the advantage of being certain the conditions could not have been present before a patient was admitted.

“It (obstetrics-gynecology) is the single most frequent area for total (Air Force) admissions,” Gertman said. “It has some clearly definable complications so you can measure bad things that happen in the hospital much more straightforwardly for this than for other (specialties).

Three large civilian companies for whom Health Data Institute has done similar work agreed that the institute’s analysis has been unfailingly reliable and has withstood withering criticism from hospitals in the past. Health Data Institute says it has done consulting projects for 30 of the nation’s 100 largest companies.

Chrysler Corp., the Equitable Life Assurance Society of the U.S. and Minnesota Mining & Manufacturing Co. all vouched for the accuracy of past studies by the institute. Chrysler said Health Data Institute surveyed care rendered to 80,000 Chrysler workers in 1982 and found that hospitals in southeastern Michigan routinely padded bills and unnecessarily extended hospital stays.

Hospitals, said a Chrysler spokesman, initially charged the institute had totally misrepresented their practices, but, said Chrysler, the health centers later were forced to concede all of the criticisms were justified. Health Data Institute said computer programs used in the Air Force study were essentially identical to those already in use for major corporate customers.

A 3-M spokeswoman said that company selected Health Data Institute as its consultant two years ago because of its “national reputation” and prominence in the field of hospital utilization. Equitable said it has employed the institute in analysis of health care provided by its largest corporate clients--all of them companies spending more than $100 million a year.

Ed Nordgaard, an Equitable national vice president, said that though the institute has not done a study for the company identical to the analysis it conducted for the Air Force, “I am sure there is no question they would have the expertise to intelligently review that type of thing.”

While the Air Force review may be the most controversial piece of work the institute has done, Gertman said that the study also raised some of the most disquieting questions he has ever confronted. Before founding Health Data Institute, Gertman established a national reputation as a health-care quality-control expert, officials of clients of his firm said.

What is alarming about the Air Force findings, Gertman said, is that the automated study--which included reviews of 243,000 patient records throughout the Air Force hospital system--was the first systematic attempt to compare the quality of military medicine in general to that of the civilian sector and that the comparison found military care is far worse than its civilian counterpart.

It has been the difficulty in comparing the two--especially the lack of any organized data base that would make such comparisons possible--that has thrown obstacles in front of several congressional investigations begun in the last year in an attempt to determine whether military medicine is worse, better or the same as what is practiced in the civilian community.

Horror Stories

Gertman said Health Data Institute was retained by the Defense Department after House and Senate committees started holding hearings on the quality of armed forces health care. The hearings were prompted by growing numbers of anecdotal horror stories--some of them more than a decade old--that reached the offices of legislators or were recounted in magazine articles scattered across the country.

“The question in my mind when we started,” said Gertman, “was: Were these (the horror stories and other accounts) isolated events or were they simply sort of the tip of the iceberg of some more systematic problems in the quality of care?

“I think the study revealed these were not isolated episodes. There are some systematic problems. (They involve) not individual physicians, but whole facilities. There is more than just (the) single physician involved in the problem. I think this study raised some non-anecdotal issues even broader than (scare story) accounts of malpractice. It found the Air Force was way out of line and it (the study) has essentially left open a series of very important questions that somebody needs to get answered.

“I’d be delighted if it turns out our findings are wrong, but even if the findings are wrong, they suggest the possibility of a problem so significant that aggressive, immediate action is really required to see if this runs into the other services, too.”

The Health Data Institute study was commissioned by the office of the assistant secretary of defense for health affairs specifically to try to resolve questions about comparability. The study was undertaken, Gertman said, at the personal urging of Defense Secretary Caspar W. Weinberger. Health Data Institute was paid about $100,000 for its Air Force analysis and had recommended a series of urgent follow-up studies--first of the Army and then of the Navy--that would have cost about $1.5 million, German said. It was those studies that the Defense Department canceled as word spread of the Air Force findings when the report was first submitted in February.

The findings, Gertman said, are doubly worrisome because the Air Force deliberately was selected to be the first service scrutinized because, overall, it has the most modern health centers among the armed forces and enjoys a reputation for better quality care than the Navy and the Army in some circles. However, most observers rate the Army or Air Force first in quality in military medicine with the Navy third.

Among its conclusions, the Health Data Institute study found no significant difference in the volume of severe problems among small Air Force base-level hospitals, bigger regional hospitals comparable to medium-size community hospitals and a half dozen Air Force medical centers where the service provides the most advanced and sophisticated types of care.

Care Around the Globe

Worldwide, the Air Force has six big medical centers and a total of 77 hospitals, 41 clinics and 73 aid stations with a total of 5,865 beds. Types of all three major facilities are represented in California, where problems uncovered in the study are representative of deficiencies said to exist throughout the service. Among the California problems were:

--David Grant Medical Center, Travis Air Force Base, Solano County, one of the largest Air Force facilities in the country. Third-degree perineal laceration (tears of the vaginal area) rates were recorded at the rate of 74 per 1,000 deliveries, compared to the Air Force average of 49 per 1,000, which, in turn, was more than double the civilian rate of 20.

--Air Force Regional Hospital, March Air Force Base, Riverside. March significantly exceeded the Air Force-wide rate for postpartum hemorrhage of 31 per 1,000 deliveries, which is 50% greater than the civilian rate. At March, women suffered this complication in 47 of every 1,000 cases. March also recorded excess rates of high blood pressure in pregnancy and failure of mechanical medical devices. March recorded a rate for a common type of heartbeat disturbance called atrial fibrillation that was significantly greater--9.5 cases per thousand versus 5.6--than the Air Force as a whole. Health Data Institute said the significance of the atrial fibrillation rate was that it implies Air Force doctors in walk-in clinics provide “inadequate” drugs and other treatment in many potentially serious heart cases.

--Mather Air Force Base Hospital, near Sacramento. Mather recorded some of the worst postoperative hemorrhage and postoperative infection rates observed in the Air Force system. It showed poor results in high blood pressure in pregnancy and recorded the second-highest incidence of ruptured appendix--263 of every 1,000 cases treated. The rate for the Air Force as a whole was 122. March’s rate of appendix rupture was higher than at the Air Force Academy in Colorado Springs, where, Gertman said, Health Data Institute concluded there was an abnormally high rate because of fear of reporting to sick call among cadets.

--Edwards Air Force Base Hospital, near Lancaster. Edwards emerged as one of six small Air Force hospitals with high Caesarean section rates--a larger rate than the national proportion of 20.3% among civilian facilities (a ratio many observers believe is far too high). At Edwards, 26.4% of women delivering were given sections--the highest rate in the Air Force.

--Beale Air Force Base Hospital, Yuba County. Beale was second to Edwards in its Caesarean section rate, with 25.7% of women who delivered at the small hospital there having sections. Beale patients had nearly twice the Air Force-wide rate of congestive heart failure--16.3 per 1,000 patients at Beale versus 8.7 for the Air Force as a whole. Earlier research by Gertman suggested that some congestive heart failure patients have difficulty when they are not hospitalized long enough when their conditions are first recognized--a shortcoming that can lead to recurrence.

--Castle Air Force Base Hospital, Merced County. Castle had the second-highest rate in the Air Force for trauma during childbirth--resulting in central nervous-system damage, fractures or other problems. The civilian U.S. rate is 14.6 per 1,000 deliveries. Castle’s was 34 per 1,000. Castle also had an abnormally high rate of vaginal tears during delivery and recorded a rate far higher than the 24.7% in the Air Force at large for deaths during the first day of a hospitalization measured as a percentage of all deaths. Fully 50% of Castle’s deaths came on the first day after admission.

Air Force Objects

When the Defense Department got the Health Data Institute report, the Air Force strongly objected. A civilian consultant, Dr. Kermit Krantz of the University of Kansas Medical Center in Kansas City, was sent to Andrews Air Force Base outside Washington to conduct a validation review.

Results turned in by Krantz--who has been associated with the Air Force for nearly 20 years but does not hold military rank and who enjoys an excellent national reputation in his field--asserted, however, that in the Andrews records, there were many instances where medical records inexplicably overstated the severity of the condition in question. Because of the alleged pattern of overstatements, which led to numerous alleged coding errors in the computer data, Krantz reported he found nothing amiss but the procedures by which entries are made in Air Force medical files. There was no problem with the actual care, he said.

“I found the nomenclature was wrong, but they (the records) were in compliance” with acceptable standards of care, Krantz said. “Within the armed forces, medical care is equivalent to any civilian group in the U.S. and superior to most.”

Col. Buethe, the Air Force director of medical plans and resources, agreed with Krantz, saying: “We have no problem with quality of care or availability. The Air Force has always been very, very careful not to stretch a guy (a physician specialist) too thin. We’ve been on the forefront of that. We don’t have any major system problems.”

The statement was echoed by Dr. William Mayer, defense undersecretary for health whose office released a statement saying that, despite the Health Data Institute research, “There is no evidence that the quality of care was, by any standard, less than expected.”

However, Mayer’s office declined to say what action--if any--had been taken to implement a series of follow-up steps he had outlined when the institute report was originally released in February.

At the time, Mayer’s office said a variety of reviews in addition to the single base audit by Krantz would be undertaken. Promised were reviews of surgical care by specialists, revision of screening criteria of obstetrics-gynecology cases in all three services with a 6-month trial of the new procedures to begin this year, and use of computer analysis software prepared by Health Data Institute to conduct an in-service evaluation similar to work the contractor did but controlled by the Defense Department.