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
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
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
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
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
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
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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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
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
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
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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