I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Headquarters U.S. Air Force

Athletic Trainer Integration within

Basic Military Training

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Shandra Esparza EdD, ATC, LAT

Reid Fisher EdD, ATC, LAT

21 Aug 2019

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Overview

■ Background

■ Study Design and Concept

■ Results

■ Discussion

■ Conclusions

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I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Overview

■ The views expressed are those of the authors and do not

reflect the official views or policy of the Department of

Defense of its Components.

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I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Background Sports Medicine Support in BMT

■ The Perfect Storm – BMT, PrevMed, Sports Med

■ $980k, 36-month injury prevention grant

■ BMT is gateway for ALL USAF enlisted, ~ 40,000 trainees/year

■ Many have sedentary lifestyle prior to accession

■ AF Goals

■ Increase graduation on time rates, Train Smarter!

■ Provide operational training leaders support to reduce injury

burden

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I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Hypotheses & Study Design

Hypothesis: Embedding Sports Med Team in BMT would reduce

Musculoskeletal (MSK) attrition

Training and medical costs

Time away from training due to injuries

Study Design:

Prospective randomized (quasi) controlled study over 3 years

Intervention: 323rd Training Squadron

2 Full-time ATs with UIW oversight

1 Full-time Sports Med. Physician

Controls: 321st & 322nd Training Squadrons receive usual

Trainee Health Clinic care

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I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Embedded ATR and Hub Clinic

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Embedded ATR

Hub Clinic

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Applies college/professional sports model of care

(lessons learned) to military training

Collaborate with Military Training Instructors and Leadership

to “keep them in the game!”

Sports Medicine Team

Athletic

Trainer

Trainee /

Athlete

Training

Leaders Medical

Team

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Results

Summary

323 TRS compared to controls (321 and 322 TRS)

■ Decreased MSK attrition 25%

■ Decreased all-cause attrition 15%

■ Avoided $10,888,056 training attrition costs

■ Decreased absenteeism from training 14%

■ Decreased specialty utilization (Ortho, PT/OT)

■ Increased physical fitness

■ Possibly increased overall healthcare cost (??)

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321/322 TRS 323 TRS Risk Ratio (95% CI)

Operational Outcomes*

Overall Attrition (%) 6.81 5.81 0.85 (0.80, 0.91)

MSK attrition (%) 1.25 0.94 0.75 (0.64, 0.89)

Any medical attrition (%) 2.49 2.00 0.80 (0.72, 0.90)

Change in fitness score§ +11.9 +19.7 - -

Med Hold referrals (%) 6.83 5.76 0.84 (0.79, 0.90)

*All results shown are statistically significant. Null results include mental health and administrative attrition,

Get Fit referrals, and On-time graduation §P value is < 0.05

Results

Operational Outcomes

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321/322 TRS 323 TRS Rate Ratio (95% CI)

Medical Outcomes (rates per 1000 trainee-day)

Encounters for Inflammation and Pain 4.2 6.1 1.46 (1.41, 1.50)

Encounters for Lower Extremity Injury 9.4 8.7 0.92 (0.90, 0.95)

Incidence of Lower Extremity Injury 1.7 1.9 1.11 (1.05, 1.17)

Encounters for Stress Fracture 5.1 2.9 0.57 (0.55, 0.59)

Incidence of Stress Fracture 0.3 0.2 0.84 (0.73, 0.97)

Incidence of All MSK 1.9 2.2 1.12 (1.07, 1.18)

Ortho Encounters 0.17 0.08 0.43 (0.34, 0.54)

PT/OT Encounters 5.1 1.8 0.35 (0.33, 0.36)

Trainee Health MSK Encounters 4.6 7.5 1.63 (1.59, 1.68)

All MSK Encounters 9.9 9.4 0.95 (0.93, 0.97)

Results

Medical Outcomes

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321/322 TRS 323 Expected* 323 Actual Savings

Attrition

MSK Attrition 444 260 195 65 (↓25%)

All Cause Attrition 2,423 1,417 1,210 207 (↓15%)

Training Days Lost 110,520 64,623 53,110 11,513 (↓18%)

Absenteeism for MSK Visits

Orthopedics 379 210 91 119 (↓57%)

Physical/Occupational Therapy 11,008 6,111 2,123 3,988 (↓65%)

Trainee Health (MSK only) 9,913 5,503 8,992 -3,489 (61%)

All MSK Visits 21,557 11,825 11,206 619 (↓5%)

Missed Hours for MSK Visits§ 150,574 83,590 71,664 11,926 (↓14%)

Fiscal Costs

Training (Attrition) Cost† $116,303,968 $68,004,652 $57,047,520 $10,888,056

*Expected is based on 321/322 TRS multiplied by ratio in trainees entered (attrition) or in training-days (for rates)§Time is 8 hours for orthopedics and PT/OT (4 for patient and wingman) and 6 hours for trainee health†Cost is $25,376 to recruit, process, and ship one new trainee plus $496 per training day¥Additional savings anticipated with decreased time away from training ($16 per hour), but not independent of MSK

attrition savings

Results

Personnel/Fiscal Savings

*Sports Med physician deployed Oct 2016-May 2017, backfilled by GMO. Orthopedic referrals increased

during the period

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343rd Current Impact

Security Forces

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CY 2017

Class Appointments Percent

Time out of training

(Hours)

Expected time out of training

(Hours) Impact

(Hours Saved)PREVENTED

RECYCLE

SFAC 1400 58.7 500 6,720 6220 300

CLC 629 26.4 120 480 360 20

SFOC 176 7.4 20 320 300 10

Cadre 156 6.5 75 935 860 N/A

Yearly Total: 2383 100% 7740 hrs 330

Time Out of Training / Recycles

SFAC = SF Apprentice Course (Tech school)

CLC = Combat Leaders Course (NCO’s)

SFOC = SF Officer Course

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Results

Effective model for embedded MSK care

ATs + Sports Medicine physician = successful partnership

Expanded team also have roles, but not studied

Athletic Training productivity standards

Clinical Care RVU vs METLS

AT SOP, treatment protocols

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Discussion

■ Cost avoidance by decreased attrition & lower lost training time

■ Shifted MSK care from clinics/hospital to embedded locations

■ Less absenteeism from mandatory training

■ Scheduled around requirements

■ VIPER lowered barrier for trainees to seek care

■ Care provided earlier in the course of injury

■ Improved trust and optimism, trainees feel AT is advocate

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Discussion

All-Cause Attrition

■ All-cause Attrition decreased 15%,

■ Intangibles

■ Improved MSK injury care may improve trainee self-efficacy

■ Synergistic effects of keeping Flights together

■ Less time sitting in waiting rooms and losing motivation

■ Reduced fitness failures

■ Interaction with civilian AT may help relieve stress of BMT

■ Leadership see results, believe in Sports Med team

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DiscussionPotential Long-Term Results

Kicking the can down the road? Helping people get into USAF

who don’t belong?

Fitness scores improved!

Running gait training for “Red Belters” and injured trainees

Alternate cardio during PT instead of sitting

Injury prevention, program improvement benefit all

Long-term outcomes study underway

Anecdotally – we treat everyone, good trainees get hurt too!

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Future Direction

HUB CLINIC

2 Sports Med docs

PA or GMO

2 RD’s, 1 EP, 1 PT

Head AT / Asst.

2 Staff ATs

319 TRS

1 AT320 TRS

3 ATs

321 TRS

3 ATs

322 TRS

3 ATs 323 TRS

3 ATs

324 TRS

3 ATs

331 TRS

3 ATs

343 TRS

3-4 ATs

1 RD

PHASE II – BMT Wide + 343rdPHASE I – Proof of Concept

*Part-time from the University of the Incarnate Word

(SF)

343 TRS

2 ATs

(BA)

350 TRG

2 ATs

(BMT)

= Tech School= BMT

N = 8,000 / yearN = 40,000 / year

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VIPER

Conclusions

Embedded ATs/Sports Med reduces MSK attrition/lost training time

FOUNDATION

Partnership with University of Incarnate Word AT Program

AT SOP, treatment protocols

Strong support from 559 MDG, 737 TRG

Model for effective embedded MSK care in USAF

Contracting support to transition program lacking

Untimely delays (Valley of Death)

Line funds, embedded medical providers, medical facilities

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I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Questions?

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