Annual Report the Surgeon General United States Army Fiscal Year 1960
PATIENT CARE AND RELATED ACTIVITIES
Hospital Clinic Care
The increasing shift of emphasis in the U.S. Army Medical Service from inpatient care to treatment of patients on a clinic or ambulatory basis has necessitated a reappraisal of hospital clinic activities and procedures. The aims are to-
1. Improve interpersonal relationships through greater recognition of individual dignity.
2. Provide for more effective and efficient use of personnel, space, and equipment.
3. Reduce waiting time for patients.
4. Eliminate overcrowding in clinics.
5. Improve the appearance and atmosphere of clinics.
Waiting room of outpatient clinic in an Army hospital
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At present, AMEDS personnel see more than 12 million outpatients as compared to about one-half million inpatients annually, including military dependents. It is obvious that it is necessary to shift some professional and nonprofessional personnel from inpatient to outpatient care in order to preserve patient-doctor continuity. Experience in the care of ambulatory patients in hospital clinics is an essential and vital part of the intern and residency training programs, regardless of the specialty. Under the new clinic care concept, there will be an increase in the outpatient workload of the hospital because of improved organization and efficiency of the clinic service. In fact, the increased emphasis on outpatient care is not only medically sound but also is more economical in the utilization of personnel and facilities. While the most recent medical facilities are not designed to provide adequate space, it is expected that expert study of the most efficient arrangement interior furnishings, floor space, flow of traffic, communications, clinic records, and patient-appointment schedules will enable each hospital commander to meet the aims previously listed. During the past year, significant steps have been taken in this direction, with appreciable contributions toward improving morale and well-being among military personnel and their families and enhancing the military service as a career.
Outpatient waiting room, during military sick call, DeWitt Army Hospital, Fort Belvoir, Va.
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Professional Consultant Activities
One of the most useful and effective activities of the professional consultants to The Surgeon General is that of visiting medical treatment facilities. Representatives from each major consultant's office visit CONUS hospitals at least once a year and oversea installations at least once every other year. For many years, representatives of the Physical Standards Office, OTSG (Office of The Surgeon General), have visited each of the 73 AFES (Armed Forces examining stations), usually as members of a Department of the Army team. An innovation during the past year has been the inclusion of certain AFES in the itineraries of the professional consultants. It is expected that these additional visits will contribute to the improvement of the quality of AFES medical examinations for enlistment and induction.
In addition to the professional consultants in the Professional Division, OTSG, there are specialists in every professional field who serve as part-time consultants to The Surgeon General in addition to their regular military duties. These specialists participate in many national and international meetings as well as in professional programs of various Army hospitals. Occasionally, they are also available to make directed staff visits.
In accordance with President Eisenhower's suggestion that professional military officers be used 'to enhance and help develop the feeling of friendliness and helpfulness of peoples,' increasing emphasis is being given to the role of the U.S. Army medical officer in furthering this foreign-policy objective in oversea areas.
General Medicine
The Surgeon General's chief medical consultant, or the consultant's assistant, visited nearly every Army hospital in CONUS during the fiscal year to evaluate local problems pertaining to professional care and to assist in solving them. This close liaison between the OTSG and local medical personnel is resulting in better professional assignment policies and in improved patient care. The medical consultants continued to stress the importance of outpatient care and the integration of outpatient and inpatient care, and they advised hospital commanders and medical officers on how to provide better outpatient care.
Particular emphasis continued to be placed upon the desirability of having well-qualified Regular Army officers in charge of professional services and sections of Army hospitals because of their knowledge of Army methods and procedures, their continuity of service, and their identification with the Army. Most Army hospitals now have a board-certified or board-qualified Regular Army medical officer as chief of
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the medical service. Similarly, at least one board-certified or board-qualified Regular Army officer is assigned to each pediatric service. Of the 32 dermatology spaces now filled, 30 are occupied by Regular Army officers and 2 by reservists. By the summer of 1961, there will be sufficient Regular Army dermatologists to occupy all the present spaces and to provide dermatologists to all other Army hospitals if spaces can be allotted. There are a sufficient number of board-certified or board-qualified Regular Army cardiologists to fill all the cardiology spaces. In another year, all gastroenterology spaces will be filled by fully qualified
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gastroenterologists. Although there are only two fully trained allergists in the Regular Army, this number fulfills the present space requirements. More allergists could be used, but authorized spaces are not available.
Approximately 90 percent of the teaching positions in internal medicine in the Army teaching hospitals are filled by career medical officers. It is expected that 100 percent Regular Army staffing of these teaching positions will be accomplished during the next year. The establishment of radioisotope clinics in class I teaching hospitals is moving somewhat slower than anticipated because of the press of other daily clinical workloads which require higher priority. This problem could be alleviated if additional personnel spaces were available. The 1-year training program in endocrinology continues with Dr. Peter H. Forsham at the University of California Medical School in San Francisco. It is planned to include internists with special training in endocrinology and in hematology on the staff of each teaching hospital.
Four civilian consultants, outstanding authorities in internal medicine or an allied specialty, visited Army hospitals in the Far East and Europe during the year. They not only stimulated local medical teaching and practice but also served as observers helping The Surgeon General evaluate medical care.
During the year, TB MED (technical medical bulletin) 230, Treatment and Management of Venereal Disease, was completely revised and published in December 1959. TB MED's 202, Allergy, and 231, Prevention of Spread of Tuberculosis in Army and Air Force Hospitals, are being revised.
Tuberculosis is losing its importance as a military medical problem. During World War I and in the years that followed, tuberculosis was the cause of a tremendous loss of manpower to the Army and of enormous expense to the country in terms of disability pensions and hospital care. In World War II, careful screening before induction greatly reduced the manpower losses due to tuberculosis, but treatment of the disease was never satisfactory. The relapse rate after any therapeutic method was so high that it was not practical to return the afflicted soldiers to military duty. All patients with active disease were therefore permanently separated or retired from service.
Over the past 10 years, this situation has completely altered. With the introduction of specific drug therapy and the development of new surgical techniques, it has become possible to treat successfully and to return to active duty more than 90 percent of well-trained, career-motivated soldiers either immediately after treatment or after temporary retirement. In more than 3,000 military patients treated in this manner,
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the relapse rate has been less than 2 percent, with a resultant savings to the Government of more than a million dollars annually.
Surgery
The Army Medical Service made considerable progress in expanding its capabilities in cardiac catheterization and open-heart surgery. An active open-heart surgery program was maintained at Fitzsimons General Hospital, the first U.S. Army hospital to have these facilities. Similar clinical programs were instituted at Letterman and Walter Reed General Hospitals. Preliminary training of personnel, modification of physical plants, and acquisition of the necessary equipment for additional programs were begun at William Beaumont and Brooke General Hospitals.
Open-heart surgery being performed with aid of the newly developed heart apparatus
The previously existing shortages of qualified surgeons in all the surgical specialties, except general surgery, has been completely alleviated as anticipated through procurement under the Berry Plan
(Armed Forces Reserve Medical Officer Commissioning and Residency Consideration Program).
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Training in the surgical specialties has been expanded by the approval of residency programs in orthopedics at Tripler Army Hospital and William Beaumont General Hospital and of a residency program in general surgery at Madigan General Hospital. Approval was also obtained to extend residency training in general surgery at William Beaumont General Hospital from a 3- to a 4-year program.
The Surgeon General's chief surgical consultant visited U.S. Army hospitals in CONUS and USARPAC (U.S. Army, Pacific) during the year to confirm personnel requirements, to discuss professional medical care, and to help resolve problems involving supplies and equipment. He reported that the quality of professional care, as assayed by ward rounds, was excellent.
Psychiatry and Neurology
Developments in fiscal year 1960 were indicative of further progress in the field of preventive psychiatry and expanded care for active-duty personnel and their dependents. Through the media of inservice short courses in Social and Preventive Psychiatry and Current Trends in Army Clinical Psychology at WRAIR (Walter Reed Army Institute of Research), the 10th annual Army Social Work Conference in Atlantic City, N.J., and the 2d annual Conference of Army Clinical Psychologists in Cincinnati, Ohio, the members of the psychiatric teams critically viewed their methods of operation in order to develop more efficient means of dealing with the noneffective soldier and to meet the ever-increasing demands for psychiatric service to dependents.
The hospital and quarters admission rate for psychiatric conditions in the past year decreased, for the third consecutive year, to 7 per 1,000 average strength, a new low in the rates that have been recorded since 1938. The average bed occupancy for Army psychiatric patients in CONUS declined from 560 per month in calendar year 1958 to 452 per month in calendar year 1959. Coincident with the lowering of psychiatric admissions, the outpatient treatment rate for neuropsychiatric conditions rose from 200 per 1,000 average strength in 1959 to 212 in 1960, demonstrating that more and more individuals continue to receive psychiatric evaluation and treatment without the necessity of hospitalization and loss of duty time. Personnel of Army mental hygiene consultation services, of division psychiatric services, and of other outpatient psychiatric facilities have, as the result of their preventive psychiatric endeavors, continued to influence favorably other manifestations of noneffectiveness. Discharge rates for reasons other than honorable decreased from 19 per 1,000 average strength in calendar year 1958 to 11 in calendar year 1959, while discharge rates for
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inaptitude or unsuitability (honorable-type discharge) increased from 6.2 per 1,000 average strength to 10.4 for the same period of time. These latter rates reflect the early identification and discharge of individuals with behavioral abnormalities before they become involved in military offenses requiring a more punitive type of discharge and a needless expenditure of funds to support their incarceration in the stockade or disciplinary barracks. A continued decline in court-martial and prisoner confinement rates during 1959 is further evidence of a more realistic and progressive approach in dealing with the noneffective soldier.
During the past year, approximately 160 psychiatrists, 18 neurologists, 119 social work officers, and 41 clinical psychology officers were on active duty, exclusive of those in residency or other graduate training. For the first time, neurologists were assigned to the larger class I hospitals (500 beds), and social work officers were assigned in Alaska, Okinawa, and Panama, and to Fort Huachuca, Ariz., and Fort Lee, Va. The senior social work officer in Europe was designated as social service consultant in addition to his other duties. Although there was still a critical shortage of clinical phychologists, more were on duty in fiscal year 1960 than in 1959, and, on the basis of current developments, this situation is expected to improve in the foreseeable future. Recommendations have been made to enhance the attractiveness of both clinical psychology and the social work specialist career pattern by allotting spaces for enlisted personnel in grades E-8 and E-9, by scheduling proficiency testing, and by adopting plans for an advanced long course to be conducted at the Army Medical Service School, Fort Sam Houston, Tex.
Professional training flourished in fiscal year 1960. Thirty-seven medical officers were in some stage of residency training in psychiatry, and specialized training in child psychiatry was initiated through affiliations between Walter Reed General Hospital and Children's Hospital the District of Columbia and between Letterman General Hospital and the Langley Porter Neuropsychiatric Institute in San Francisco. Training in milieu therapy for schizophrenia was given to several of the residents in psychiatry at Walter Reed General Hospital. Two career psychiatrists were supported in psychoanalytic training. By the end of the fiscal year, 10 social work officers had completed the doctoral training program in social work, thus providing a nucleus of officers possessing special capabilities in research, teaching, and program administration. Thirteen officers were in the Army Graduate Clinical Psychology Program. Six were serving their year of internship and the other seven were in residence at their respective universities. The American
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Psychological Association evaluated the clinical psychology internship programs at Walter Reed and Letterman General Hospitals and placed the hospitals on the accredited list of institutions offering this training.
Significant improvements in psychiatric treatment were made in the management of the chronic alcoholic and the psychotic female dependent. In response to command interest for more medical intervention, a number of psychiatrists independently developed treatment programs for the problem drinker. The more successful programs seem to have been those which had the full support of command and which were based on the approach used in industry; namely, that an organization will not continue to employ an individual whose drinking habits impair his effectiveness to the organization. As in industry, the soldier is given every assistance to change within a reasonable length of time. If this fails, he is discharged without prejudice.
With the construction of new 500-bed hospitals, such as Martin and Womack Army Hospitals, facilities became available to implement the policy of inpatient treatment for selected cases of psychotic females without transferring them to a designated Army neuropsychiatric treatment center or to a civilian psychiatric facility. These patients require several weeks of hospitalization and drug therapy to produce a sufficient remission to allow them to rejoin their families. They are subsequently maintained on an outpatient status with psychotherapy and a maintenance drug dosage.
Many of the MHCS's (mental hygiene consultant services) have either established or expanded an already existing field program in which the social work specialist, under the supervision of officer personnel, evaluates problem soldiers in their unit areas. In addition, the officer personnel of the clinic have become more cognizant of their staff advisory role and have utilized it to aid command in the more realistic management of the noneffective soldier.
A number of research projects pertaining to the noneffective soldier have been initiated by MHCS's with the clinical psychologist as the principal investigator. Two such projects, at Fort Dix, N.J., and Fort Bragg, N.C., are supported by research and development funds. The U.S. Army Medical Research and Development Command is also giving financial support for a study at Walter Reed General Hospital pertaining to 'Patterns of Family Relationships in Families With Disturbed Children.'
The First Court-Martial Screening Program for disciplinary offenders, begun in the previous fiscal year, gained additional support and has become an established procedure on many military posts in CONUS. This program has not as yet become a standard procedure, as has the stockade screening program, because of the erroneous belief by some
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that it will usurp command authority. However, as more MHCS's accept and implement a field program, there seems to be less resistance to the First Court-Martial Screening Program.
Personnel assigned to the Professional Division served on the Experimental Psychology Study Section and the National Advisory Council for Mental Health at the National Institute of Mental Health, on the Committees on National Defense and Disaster and Civil Defense of the American Psychiatric Association, and on the Group for the Advancement of Psychiatry Committee for Cooperation Among Governmental Agencies. Lectures were given at the U.S. Military Academy, the Armed Forces Staff College, the Army Medical Service School, the Army Management School, the Walter Reed Army Institute of Research, the Armed Forces Institute of Pathology, the Judge Advocate General School, the Savannah Ordnance Depot, and at MEND (Medical Education for National Defense) programs of several medical schools. In addition, the social service and clinical psychology consultants participated in the Golden Anniversary White House Conference on Children and Youth.
Social work.-Emphasis on the application of the social science theory was the most distinctive change in military social work practice during fiscal year 1960. The most successful social work programs were those which included active liaison with key persons in the individual's environment and a concurrent assessment of the social determinants of behavior, with special focus on family and group relationships. The entire program of the 10th annual Army Social Work Conference at Atlantic City, in June 1960, was devoted to the study and analysis of the social science theory, with a view toward more effective integration of these concepts in program operations. An analysis of practice revealed that the Army social worker focuses on the 'here-and-now' functioning of the individual. The integration of social factors with personality factors has resulted in more effective individual and group treatment.
Careers in Army social work are apparently attractive, as indicated by the high percentage of officers who decide to remain in the Army as career officers after completing their obligated tours of duty. At the close of the fiscal year, 80 percent of the social work officers on active duty were either Regular Army or career Reserve officers in the indefinite category, as compared to 75 percent a year ago.
The graduates of the advanced civilian education program for social work officers are meeting expectations. Contributions to theory and practice through research, writing, and teaching by graduates of doctoral programs constitute one of the most promising aspects of the Army social work program.
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Pathology and Laboratory Activities
Pathologists.-Of the Regular Army pathologists on active duty, 92 percent are board certified; of the Reserve on active duty, 53 percent are certified. Of the total number of pathologists on duty, 76 percent are in CONUS; the remainder are overseas in Germany, France, Japan, Korea, Okinawa, Thailand, Malay, Lebanon, England, Egypt, Puerto Rico, and the Belgian Congo. One pathologist was on exchange with the Royal Army Medical Corps. About 20 percent of the pathologists are working full time in research.
Two pathologists became certified in forensic pathology, a new specialty board founded this year.
The Surgeon General's chief consultant in pathology and laboratory science visited Russia in September 1959 as a special representative of The Surgeon General. The consultant also inspected medical facilities in USAREUR (U.S. Army, Europe) in June 1960. Staff visits were also made to laboratories in CONUS.
One pathologist studied tropical medicine and parasitology for 2 months, in the Caribbean countries, under a fellowship of Louisiana State University.
Training.-The residency program in pathology was reduced by three spaces in fiscal year 1960 because of the reduction in overall total residency spaces in the Army Medical Service. This reduction involved Fitzsimons, Madigan, and William Beaumont General Hospitals by one space each. There are now 32 residents in pathology training at Army teaching hospitals, as compared to 35 a year ago. Of the 32 residents, 20 percent are Air Force personnel. All residents receive training in both clinical pathology and pathologic anatomy.
There have been no civilian residencies in the past 5 years.
Each year, one pathologist has attended the Military Medicine and Allied Science Course (8-A-F6) at WRAIR. Several pathologists attended the 8-A-C22 course at BAMC (Brooke Army Medical
Center), Fort Sam Houston.
Civilian postgraduate training for laboratory science officers was continued throughout the year. Eight MSC (Medical Service Corps) officers who are participating in the civilian postgraduate training program were authorized to continue their training in the various laboratory science specialties leading to a Ph. D. degree. In addition, six MSC officers were approved for civilian schooling beginning in September 1960-one for a master's degree in microbiology, three for the Ph. D. degree in biochemistry, and one for the Ph. D. degree in immunology. Vacancies exist in MOS (military occupational specialty) 3307 (bacteriologist), MOS 3309 (biochemist), MOS
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3311 (parasitologist), and MOS 3314 (clinical laboratory officer).
The course entitled 'Current Trends in Laboratory Activities," held at WRAMC (Walter Reed Army Medical Center), on 5-10 October 1959, was attended by selected MSC laboratory officers.
The 'Refresher Course for Laboratory Medical Officers" was held at WRAMC, on 8-13 February 1960.
Officer personnel attended the Chemical, Biological, and Radiological Weapons Orientation Course at Dugway Proving Ground, Utah, on 26-31 October 1959, and the Medical Aspects of Missile Operations course at Patrick Air Force Base, Fla., on 4-8 April 1960; these were courses presented by services other than the Army Medical Service.
Laboratories.-Army area laboratories participated, upon request, in the examination of cranberries for all governmental agencies when a chemical contamination was suspected.
Laboratory equipment of TOE organizations has been reviewed for modernization and adequacy.
Publications.-Army Regulations No. 40-400, Army Medical Laboratories, was revised; TB MED 237, Collection and Preparation of Specimens for Shipment to Medical Laboratories, is being revised; and TM 8-300, Autopsy Manual, was published.
Pharmacy
Increased prescription workloads together with a recurring shortage of enlisted graduate pharmacists contributed to the problem of staffing pharmacies in in fiscal year 1960. The shortage of pharmacists resulted from the reduction in the draft quotas and the participation by draft-eligible pharmacists in the 6-month active-duty-for-training program. In an effort to minimize the shortage, assignment procedures for drafted pharmacists were refined, and increased emphasis was placed on the acquisition and the use of laborsaving devices. A trend toward full utilization for the pharmacy officer in his professional capacity was evidenced during the year.
Emphasis continued on the training of pharmacy officers in the specialty of hospital pharmacy. Two officers were graduated in June 1960 with master's degrees in hospital pharmacy. Two other officers are now enrolled in a 1-year graduate course in hospital pharmacy. Upon completion of this academic work, these officers will be placed in 1-year residencies at Brooke General Hospital and Walter Reed General Hospital in order to fulfill the requirements for a master's degree. A career plan for pharmacy officers was completed during the year.
Changes 2 to AR 40-200, published on 14 January 1960, delegated authority to subordinate commands to purchase locally and to use those
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nonstandard drugs which have been publicly released through the Food and Drug Administration
A number of commanders of medical treatment facilities took action during the year to remodel and reequip their pharmacies. More space and equipment is required because of the shift in workloads from inpatient to outpatient services. Standard plans based on actual pharmaceutical service workloads, rather than inpatient capacities, have been completed for incorporation in the construction of new medical treatment facilities.
Nursing Service
Increasing emphasis is being placed on improving the clinical competency of Army nursing service personnel as a means of providing better care to patients. Army Nurse Corps officers who are authorized to participate in advanced training at civilian educational institutions are now enrolling in specialized clinical programs in cardiovascular nursing, child and maternal health nursing, and others. Previously, most of the advanced training was devoted to courses in teaching, supervision, and administration since these were the fields in which ANC (Army Nurse Corps) officers were most deficient. This was urgent at that time because key officers in leadership positions were often lacking in these skills. Moreover, few universities offered graduate programs in the clinical fields of nursing. The situation has changed in recent years and more and more civilian institutions are developing and conducting such programs.
With the increasing specialization and complexity of the practice of medicine generally, it is axiomatic that an ANC officer must advance in clinical competency in order to have the understanding, the knowledge, and the skills that will enable her to give adequate support as a member of the patient-care team. Those officers who have attained the advanced clinical preparation are used not only in positions of direct patient care but also in supervision, teaching, and nursing research. Only as the abilities of officers assigned to these positions continue to increase does growth continue in those with whom they work, teach, or supervise. Nursing inservice programs, conducted in all medical installations, and the clinical long and short courses, given at designated installations, are geared to increase the clinical competency of Army nursing service personnel generally as well as to improve their capabilities in specific specialty fields. Civilian short refresher institutes and workshops in clinical nursing are being attended by ANC officers in increasing numbers.
Additional ANC officers were assigned during the fiscal year to nursing methods improvement positions in hospitals. These officers study
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and evaluate activities and problems related to nursing service which have a direct or indirect effect on improvement of patient care.
Dental Service
In general, the dental health of the U.S. Army is satisfactory. Nevertheless, efforts must be directed toward preventive measures in an endeavor to reduce dental disease and time lost from duty.
Every effort is made to qualify the inductee for field service, from a dental standpoint, during his first 16 weeks of military training. A large proportion of inductees require extensive dental treatment whichresults in an inordinate amount of dental support to this segment of the Army. This requirement is magnified by the constant turnover of these personnel, many of whom remain in the service for only one enlistment.
New methods of programming and analyzing dental workloads were adopted during fiscal year 1960 and have resulted in more accurate forecasts and better utilization of reported data in determining staffing
requirements and operating costs. Dental care workloads were presented in terms of daily average dental care composite work units instead of total procedures as previously reported. The composite work unit was determined by applying the proper weights to the various procedures in accordance with the time and effort required to perform them. This method of measuring the workload has removed many of the inequalities experienced when no differentiation was made in the accomplishment of major and minor procedures.
Workloads of central dental laboratories were reported and programmed as 'daily average prosthetic units' instead of 'appliances fabricated or repaired.' This method also assigned weights to each item fabricated or required according to the time and effort expended.
Hospital Food Service
The dietetic treatment of the patient in Army hospitals will be improved as a result of the development of design and construction standards for the central tray service food cart. Previously, the Army Medical Service has been unable to procure a satisfactory food cart of this type because each manufacturer fabricated a cart different in design and construction to conform to his own specifications. Centralized procurement is planned after a pilot model incorporating the new standards is approved and total requirements have been established.
The central tray service cart with thermostatically controlled heated section for plates of hot food, heated beverage wells, and mechanically refrigerated section for the tray with cold food will improve the quality
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of the food to patients. This method of food service is flexible enough to meet the varying conditions of tray service on different types of wards in a hospital as well as the variation in physical layout in Army hospitals. At the same time, it is capable of conveying attractive, palatable food at the proper temperature to the patient with the desired size of portion as checked by the patient.
With the administration of all food service personnel and the production of high-quality food centralized in the main kitchen area, the ward dietitian is more and more recognized as the dietetic therapeutic specialist concerned with diet therapy and nutrition education. This therapeutic dietitian has time to visit each patient, attend medical ward rounds with medical officers, and develop the therapeutic dietary program of the patient.
Bed Allocations for Veterans
At the request of the Administrator of Veterans' Affairs, bed allocations in Army hospitals for VA (Veterans' Administration) patients during fiscal year 1960 were increased from 255 to 310. All the increase was at Tripler Army Hospital as a result of the admission of Hawaii as a State. The allocations are made to enable the Veterans' Administration to continue hospitalization of male veterans who require treatment for non-service-connected disabilities and are distributed as follows: Tripler Army Hospital, 155; Brooke General Hospital, 125; William Beaumont General Hospital, 20; and Walter Reed General Hospital, 10.
Care of Tuberculous Alien Dependents
Under the policy set forth in AR 40-124, dated 9 June 1958, alien dependents of active-duty military personnel who are afflicted with tuberculosis are guaranteed admission to an Army hospital in CONUS upon entry into this country. The OTSG has received and processed 326 applications (290 Army, 25 Air Force, 9 Navy, and 2 Marine Corps) for such care. These include 119 from the Far East Command and 207 from the U.S. European Command.
By the end of the fiscal year, 227 tuberculosis dependents had been evacuated to the United States. Of these, 117 were sent to Fitzsimons General Hospital, 107 to Valley Forge General Hospital, 1 to Walter Reed General Hospital and 2 to civilian institutions. In addition, two were evacuated to Tripler Army Hospital. Applications of 60 others were approved, and the dependents were awaiting evacuation to the United States; 18 applications were canceled by the sponsors; and 19 were still pending.
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Accreditation of Army Hospitals
The Surgeon General attained an important objective during the fiscal year when the Joint Commission on Accreditation of Hospitals surveyed and accredited all the 15 eligible U.S. Army hospitals in oversea areas, encircling the globe from Okinawa to Germany. This is especially significant because of the strong emphasis he has placed upon maintaining the highest degree of professional medical care throughout the entire system of Army medical treatment facilities. Virtually all eligible Army hospitals in CONUS had previously been accredited. At present, all but 1 of these 43 CONUS hospitals have accreditationand the Joint Commission on Accreditation of Hospitals has been requested to survey it. No Army hospital that has been surveyed by the commission has been rejected.
The Joint Commission on Accreditation of Hospitals evolved from the program of hospitalization standardization which the American College of Surgeons originated in 1919. The commission represents the four most influential groups dealing with health in the United States: The American College of Surgeons, the American College of Physicians, the American Medical Association, and the American Hospital Association. The accreditation program in Army hospitals was initiated in 1952.
Armed Services Medical Regulating Activities
Although the total number (21,837) of armed services patients authorized by ASMRO (Armed Services Medical Regulating Office) for movement from oversea areas and between specialty hospitals within CONUS remained relatively stable, the number of Army patients continued the steady decline that has characterized the last 4 years. The Army requested the movement of only 6,717 patients during fiscal year 1960, a decrease of about 25 percent from the Army total of 8,105 in fiscal year 1957, as compared to an overall reduction in triservice totals of approximately 8 percent during the same period. This reflects the continuing decline in the proportion of active-duty Army personnel requiring hospitalization and the fact that the Army is providing more definitive treatment in nonspecialized hospitals.
Despite the reduction in the total movement of Army patients during the year, the 3,550 Army oversea patients transferred from debarkation medical facilities to Armed Forces and USPHS (U.S. Public Health Service) hospitals in CONUS represented an increase of 168 over the corresponding number in the previous year. There were decreases, however, of 505 in the number of Army patients moved between Armed Forces hospitals in CONUS, and of 125 in the number of active-duty
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Army patients transferred from these hospitals to VA hospitals. Table 1 shows how the movement of Army patients during the year compared with those of the other services.
Table 1.-Movement of patients authorized by Armed Services Medical Regulating Office
Service | From debarkation hospitals | Between ZI hospitals | To VA hospitals | Total |
Army | 3,550 | 2,827 | 340 | 6,717 |
Navy | 2,517 | 2,215 | 612 | 5,344 |
Air Force | 1,985 | 5,691 | 342 | 8,018 |
Others1 | 1,748 | 10 | ... | 1,758 |
Total | 9,800 | 10,743 | 1,294 | 21,837 |
1Includes civilians, merchant marines, and foreign nationals.
A change was instituted in the procedure for obtaining bed designations for military patients in VA hospitals. The new procedure permits ASMRO to deal directly with the appropriate VA hospital instead of through the VA central office as was previously the case. This decentralized procedure greatly facilitates the movement of military patients awaiting transfer to VA hospitals.
A representative of ASMRO attended the semiannual conference of the Joint Medical Regulating Organization of the U.S. European Command, which convened in Wiesbaden, Germany, 6-9 June 1960, to continue discussion concerning the formulation of plans for patient evacuation under wartime conditions. In the interest of maintaining coordinated plans on a current basis, ASMRO plans to send a representative to at least one of these conferences each year.
Dependents' Medical Care Program
Restoration of most types of care.-Another major change in the Medicare (Dependents' Medical Care) Program became efective on 1 January 1960. This change restored most of the types of care which had been deleted from the program on 1 October 1958. The deletions had been made in order to comply with the expressed desires of Congress to effect economy in the operation of the program and to insure optimum utilization of the medical treatment facilities of the uniformed services (Army, Navy, Air Force, and U.S. Public Health Service). The restrictions which had been imposed proved to be more restrictive
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than had been expected or desired. Experience demonstrated that the range of care available under the program could be restored to approximately what it had been before 1 October 1958 without exceeding available funds.
All the services originally provided under the program were again made available with but two minor exceptions-neonatal and termination visits. The restored care includes treatment of injuries on an outpatient basis, emergency hospitalization for acute emotional disorders (limited to 21 days), surgery for conditions that are not classified as acute but for which good medical practice dictates prompt attention (for example, tonsillectomies), and prehospitalization and posthospitalization tests and procedures when the dependent is hospitalized for a bodily injury or surgery. The restriction on freedom of choice by the dependent in selecting the source of medical care was continued in order to promote optimum utilization of the medical facilities of the
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uniformed services. The restoration of care was authorized in a revision of DOD (Department of Defense) Directive 6010.4, Dependents' Medical Care, dated 19 November 1959. Changes in the joint regulations on Dependents' Medical Care (AR 40-121, in reference to the Army) were published on 16 December 1959.
An additional benefit was authorized earlier in the fiscal year when civilian maternity care was extended to a wife who is pregnant when her husband dies while on active duty (change to DOD Directive 6010.4, published on 28 July 1959). This was implemented by a telegram from The Surgeon General to Army hospital commanders in CONUS and overseas, on 25 August 1959, and was later incorporated in the joint regulations.
Changes in permit and reporting system.-The permit system was retained as the basic control mechanism for regulating the Medicare Program, but DD Form 1251, formerly called Medicare Permit, was revised and the title was changed to 'Nonavailability Statement.' Only dependents who reside with their sponsor are required to obtain the nonavailability statement. This statement does not automatically authorize the care requested, nor does it guarantee payment by the Government. It does serve as evidence that the dependent residing with the sponsor has cleared with the proper uniformed service authority and that the desired care is not available from a reasonably accessible uniformed services medical facility. Dependents who reside apart from their sponsor and who are eligible to receive civilian medical care may continue to choose between civilian medical facilities and those of the uniformed services when seeking that care which is authorized under the Medicare Program. Dependents residing with their sponsor are not required to obtain a nonavailability statement when it is necessary to obtain authorized care from civilian sources because of a bona fide emergency or when absent from the area of the sponsor's household on a trip.
From 1 July through 31 December 1959, only the Department of the Army required monthly reports on the issuance of nonavailability statements. The revision of the joint regulations, on 16 December 1959, extended this reporting requirement to the other uniformed services. The Surgeon General of the Army, as Deputy Program Director of the Medicare Program, now receives monthly reports from the Air Force, Navy, and U.S. Public Health Service on the number of nonavailability statements issued. Nearly two-thirds (63 percent) of the 50,564 nonavailability statements issued by the four uniformed services from 1 January through 30 June 1960 were for maternity cases and the remainder for all other types of treatment.
From 1 July 1959 through 30 June 1960, Department of the Army
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installations and activities issued 15,840 Medicare permits or nonavailability statements. Of these, 41 percent were issued because there were no uniformed medical facilities available, 18 percent because the uniformed services medical facility did not provide the type of care required, 40 percent because the facility did not have the necessary staff or was handling the maximum load in the type of care required, and 1 percent for miscellaneous reasons.
Impact of the changes in the Medicare Program.-At a hearing before the Department of Defense Subcommittee of the Senate Committee on Appropriations, on 26 February 1960, the Executive Director of the Office for Dependents' Medical Care evaluated the revised Medicare Programs as follows:
It is my sincere belief that we now have in force a sound and stabilized Medicare Program for dependents which will increasingly improve the stamina and morale of the servicemen. The program as of 1 January 1960 was arrived at after three years of operational experience and constructive revisions found necessary, (1) to insure optimum use of uniformed services medical facilities, (2) to keep the Program costs at reasonable levels, and (3) to provide the care envisioned by the Medicare Act.
There have been two major changes in the Medicare Program since it became effective on 7 December 1956. The first, on 1 October 1958, placed restrictions on the types of care available to dependents of active-duty personnel from civilian sources and partially eliminated the freedom of choice provision for those dependents residing with their sponsor until they first cleared with the appropriate military authorities. The second, on 1 January 1960, restored most of the types of care but retained the permit system and the partial restriction on freedom of choice. Chart I effectively illustrates the impact that the establishment of the program and the two subsequent changes have had not only upon the number of dependents receiving medical care but also upon the sources of that care. The top jagged line graphically portrays, from calendar year 1951 through 1956, the average quarterly admissions of dependents to the hospitals of the uniformed services, and, from calendar year 1957 to early 1960, the total admissions by quarters of these dependents to both service and civilian hospitals. The light area in the chart shows the admissions to civilian hospitals only; the bottom darker area, the admissions to service hospitals. The top line depicts the tremendous, almost instantaneous, increase at the outset of the program in the number of dependents receiving medical care, and the more gradual increase that followed, roughly paralleling the increasing number of of dependents eligible for care.
This chart illustrates the sharp drop both in total admissions and in admissions to civilian hospitals when the restrictions became effective
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CHART 1.-Impact of Medicare Program on dependents' medical care
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(indicated by first vertical line). It also depicts the sharp increase in total admissions that occurred later on when care was restored (second vertical line). This increase was primarily in civilian hospitals. The data shown for the period January through March 1960 are still provisional. The top dotted line indicates the predicted averages for the other three quarters of calendar year 1960. The estimated total is 173,000 admissions per quarter. The Medicare Program is expected to provide for approximately 66,000 admissions per quarter, or 22,000 per month.
The bottom solid area of the chart shows the effect of the Medicare Program on the dependent patient load in service hospitals in the United States and Puerto Rico. A marked decrease resulted almost immediately at the outset of the program, followed by a more gradual decrease which tended to level off. With the application of restrictions and the permit system, there was a substantial upturn in the dependent patient load in service hospitals-almost up to their estimated optimum capacity (indicated by the dotted line).
The decreases in total admissions that occurred in service hospitals after the Medicare Program began were mostly maternity cases. Chart 2 shows clearly the sharp impact that the program had on births in service hospitals. It also depicts just as clearly how the restrictions imposed in October 1958 succeeded in returning large numbers of maternity cases from civilian to service hospitals. During fiscal year 1958, the number of births in service hospitals decreased by 34 percent while births to wives of servicemen in civilian hospitals increased by about the same percent. During fiscal year 1959, under the restricted program, the situation was reversed, with births in service hospitals increasing by more than 54 percent and those in civilian hospitals decreasing by approximately 34 percent.
Officials in the Office for Dependents' Medical Care estimate that the restoration of care to dependents will result in an increase of from 10 to 15 percent in the cost of operating the Medicare Program over what it was when the restrictions were in effect.
Increase in number of eligible dependents.-Statistics show that the number of dependents eligible for Medicare is growing. Although the troop strength has declined since the start of the program, the number of married servicemen has gradually increased. The percentage of married men in the services increased from 42 percent in January 1956, to 52 percent in September 1959. The number of children per service family is also continuing to increase-from 1.27 per family in 1956, to 1.66 in 1959, a growth of 31 percent in about 3? years.
Effect of Medicare Program on morale.-The Surgeon General, in a memorandum to the Executive Director of the Office for Dependents'
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CHART 2.-Impact of Medicare Program on maternity care
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Medical Care, dated 1 March 1960, expressed his belief that, from an overall standpoint, the provision of assured medical care for dependents either in uniformed services medical facilities or from civilian sources has contributed to improved morale among service members and their dependents. He noted, however, that in some respects the Medicare Act has failed to achieve its stated purpose: 'to create and maintain high morale throughout the uniformed services by providing an improved and uniformed program of medical care for members of the uniformed services and their dependents.' He pointed out that-
1. The loss of dental care in most areas of the United States cannot be considered as contributing to improved morale. Nor has uniformity been achieved insofar as dental care is concerned since dependents located in oversea areas are authorized dental care while the majority of dependents in the United are denied such care. Further, even within the United States uniformity is destroyed since dependents are authorized dental care at certain installations have been designated as 'remote.'
2. Outpatient care is another service which is not available to dependents on a uniform basis. Dependents who live near a uniformed service medical facility can obtain routine outpatient care such as examinations, inoculations, and immunizations at that facility while dependents who are not within commuting distance of a service medical facility can obtain such treatment only at personal expense. Numerous complaints have been received from dependents who are required to have certain immunizations before going overseas and must pay for those immunizations from personal funds.
3. Prior to the Dependents' Medical Care Act, Army medical facilities were authorized to provide medical care to all dependent family members. The restrictive definition of 'dependent' contained in the Act eliminated care for dependents such as sisters and brothers, grandparents, and grandchildren whose sole support is the service member. Elimination of this care is considered to have adversely affected the morale of members having dependents in this category.
4. The October 1958 cutback in types of civilian care available under the program is considered to have resulted in some lowering of morale. However, this situation was corrected by the restoration of care on 1 January.
The Surgeon General went on to say that the availability of civilian medical care at Government expense "has been particularly beneficial for dependents of personnel assigned to Army attache offices, military missions and similar organizations located in oversea areas where there are not uniformed services medical facilities. There can be no question that the Dependents' Medical Care Program has resulted in improved morale among this group of individuals.'
He also stated in the memorandum that, in general, dependents have accepted the restrictions on freedom of choice without comment or criticism, and he expressed his belief that these restrictions neither caused any hardship nor had any adverse effect on morale.
Survey to determine abuses of outpatient care.-On 29 December 1959, the Assistant Secretary of Defense (Health and Medical) re?
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quested each of the military departments to conduct a field survey of outpatient medical care furnished to dependents in military medical facilities and to submit to his office, by 1 July 1960, a report on possible abuses or excessive demands for outpatient care by dependents. The purpose of the survey was to assist the Department of Defense in establishing a position concerning a recommendation by the Bureau of the Budget that a charge be imposed for dependent outpatient care.
A worldwide survey of outpatient care provided to dependents at Army hospitals and dispensaries was conducted for the period 1 through 30 April 1960. Of the 177 installations surveyed, 124 (70 percent) reported that no abuses or excessive demands occurred during the month. There were 1,495,795 outpatient visits by dependents to Army medical treatment facilities in April. The alleged abuses and excessive demands amounted to only 15,175, or only 1.02 percent of the total visits. The Surgeon General's report to the Department of Defense, dated 22 June 1960, concluded that alleged abuses and excessive demands are insignificant in proportion to the number of visits and do not warrant the imposition of any charge. The Surgeon General urged that the Department of Defense strongly oppose any action by the Bureau of the Budget to initiate such charges.
Payments to contractors.-Expenditures to civilian physicians and hospitals for the care of dependents declined sharply again in fiscal year 1960 because the restrictions placed upon the Medicare Program continued in effect through the first half of the year. At the end of the fiscal year, the Office for Dependents' Medical Care had processed 276,387 claims from physicians, in the amount of $21,759,824, and
181,496 hospital claims, totaling $24,264,207, from fiscal year 1960 funds. These claims and costs are not comparable to those shown in the fiscal year 1959 Annual Report of The Surgeon General because, as a result of new financial operating practices, they include only those payable from fiscal year 1960 funds. In the previous year, under the former system, the claims and costs shown represented those processed during that fiscal year without regard to which fiscal year funds were used. The administrative costs amounted to $717,157 for processing claims of physicians from fiscal year 1960 funds, and $306,479 for processing those of hospitals. Excluding administrative costs, the average physician claim declined from $80.53 in fiscal year 1959 to $78.73, but the average cost per hospital claim increased from $124.48 to $133.69. Tables 2 and 3 show how the claims and administrative costs were distributed among the four services. The percentages of claims and costs paid for the care of dependents of Army personnel were well below those of the Navy and Air Force. The claims and costs shown in the tables do not represent all authorized service provided during
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Branch of service | Claims | Costs | ||||
Number | Percent | Physicians' | Administrative | Total | Percent of total | |
Army | 64,316 | 23.3 | $ 5,143,157 | $167,656 | $ 5,310,813 | 23.6 |
Navy | 92,379 | 33.4 | $ 7,375,426 | $261,828 | $ 7,637,254 | 34.0 |
Air Force | 113,458 | 41.1 | $ 8,711,389 | $272,695 | $ 8,984,084 | 40.0 |
U.S. Public Health Service | 6,234 | 2.2 | $ 529,852 | $ 14,978 | $ 544,830 | 2.4 |
| Total | 276,387 | 100.0 | $21,759,824 | $717,157 | $22,476,981 | 100.0 |
1It is estimated that additional payments totaling about $16.5 million will be made to physicians and hospitals for care provided in fiscal year 1960 but not yet billed and processed through the Office for Dependents' Medical Care as of 30 June 1960.
Source: Records, Office for Dependent's Medical Care.
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Branch of service | Claims | Costs | ||||
Number | Percent | Hospitals | Administrative | Total | Percent of total | |
Army | 45,930 | 25.3 | $ 6,106,047 | $ 77,184 | $ 6,183,231 | 25.2 |
Navy | 59,509 | 32.8 | $ 8,219,671 | $105,259 | $ 8,324,930 | 33.9 |
Air Force | 71,722 | 39.5 | $ 9,369,762 | $116,306 | $ 9,486,068 | 38.6 |
U.S. Public Health Service | 4,338 | 2.4 | $ 568,727 | $ 7,730 | $ 576,457 | 2.3 |
| Total | 181,496 | 100.0 | $24,264,207 | $306,479 | $24,570,686 | 100.0 |
1It is estimated that additional payments totaling about $16.5 million will be made to physicians and hospitals for care provided in fiscal year 1960 but not yet billed and processed through the Office for Dependents' Medical Care as of 30 June 1960.
Source: Records, Office for Dependent's Medical Care.
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fiscal year 1960, because there is a considerable lag between the time the services are performed and the time the claims are received and processed.
Army commanders in CONUS processed 194 claims during the year and reimbursement from uniformed services personnel for bills which they had already paid out in the amount of $28,592 from fiscal year 1960 funds. In addition, they processed 252 claims, totaling $37,227, were paid out of funds obligated in previous fiscal years for care provided during those years.
Army Health Experience and Trends
General.-The health experience of Army personnel in fiscal year 1960 was extremely favorable. The major indices of morbidity either reached new lows or declined to near the record low levels, most of which had been experienced in fiscal years 1956 and 1957. Both disease and non-battle-injury rates declined from the previous year's level. The decreases occurred both in ZI and outside ZI. (The category label 'ZI,' for Zone of Interior, is used beginning with this year's annual report to refer to the geographic area occupied by all Army commands located in the 48 contiguous States and the District of Columbia. This category corresponds to the one formerly labeled 'United States,' a designation no longer appropriate since the political entity, the United States, now including Alaska and Hawaii, is broader than the geographic area encompassed by the commands grouped here. The term 'outside ZI" is used for the complementary category, which together with the category ZI constitutes the total Army. It includes Alaska and Hawaii, data for which are also shown separately in appropriate tables.)
Admission rates for all causes and for both the disease and the nonbattle-injury components declined during this year but did not quite reach the low levels attained in fiscal year 1957. The noneffective rate, however, which had established a record low in fiscal year 1959, declined still further to set a new record. The average daily number of outpatient visits of Army personnel per 1,000 strength in this year was 17.0, the same as it had been for 1959 and lower than any other previous year for which comparable data are available. (Data for the current fiscal year may be suject to slight modifications in the next annual report, as has been true of earlier data; the publication schedule requires the use of partly estimated June data in some instances.)
Admissions.-The rate at which Army personnel were admitted to medical treatment facilities in fiscal year 1960 was about 10 percent below the rate for the preceding year (table 4). Admissions for all causes occurred at a rate of 343 per 1,000 average strength in fiscal year 1960
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as compared with 379 in fiscal year 1959. The decline was greatest in the disease component of the rate (from 327 to 293), but the injury rate declined also, by about 4 percent, after having increased in the two previous fiscal years. Neither of these admission rates quite reached the record lows of fiscal year 1957 (282 and 45, respectively). The disease rate, however, represents essentially that same low level, contrasted with the higher rates experienced during and just after the influenza epidemic in fiscal year 1958. The fiscal year 1959 admission rates declined both in ZI and outside ZI, but not in every individual oversea area. The disease admission rate is shown by month in table 5 for each of the past 3 fiscal years. It is seen that the fiscal year 1960 rate reached its peak in February. Except for January and February, the rate of admission for disease in fiscal year 1960 was lower in every month than the corresponding fiscal year 1959 rate; this was true both in ZI and outside ZI.
Noneffectiveness.-A new record low in average daily noneffective rate was achieved for the second consecutive year, the rate dropping to 11.7 per 1,000 in fiscal year 1960 from the previous low of 12.3 in fiscal year 1959. Both the disease and the non-battle-injury components of the rate declined-disease from 9.9 to 9.7 and nonbattle injury from 2.4 to 2.0 (table 6). The amount of decrease in the com?
[Rates expressed as admissions per 1,000 average strength per year]
Area | All causes | Disease | Nonbattle injury | ||||||
19602 | 1959 | 1958 | 19602 | 1959 | 1958 | 19602 | 1959 | 1958 | |
Total Army | 343 | 379 | 477 | 293 | 327 | 430 | 50 | 52 | 47 |
Total ZI | 339 | 389 | 467 | 294 | 340 | 423 | 45 | 49 | 44 |
Total outside ZI | 350 | 364 | 492 | 292 | 307 | 440 | 58 | 57 | 52 |
| Europe | 353 | 372 | 501 | 292 | 310 | 444 | 61 | 62 | 57 |
| Japan-Korea-Ryukyus | 383 | 382 | 517 | 330 | 334 | 470 | 53 | 48 | 47 |
| Alaska | 256 | 339 | 488 | 204 | 282 | 433 | 52 | 57 | 55 |
| Hawaii | 287 | 271 | 351 | 243 | 231 | 320 | 44 | 40 | 31 |
1Admission to all medical treatment facilities, Army and non-Army. Excludes carded-for-record-only cases reported on summary morbidity reports, largely venereal disease cases treated while individual is on duty status.
2Data for June 1960, partially estimated.
Source: Morbidity Report, DD Form 442 (RCS MED-78).
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Period | Total Army | Total ZI | Total outside ZI | ||||||
19602 | 1959 | 1958 | 19602 | 1959 | 1958 | 19602 | 1959 | 1958 | |
12-month period | 293 | 327 | 430 | 294 | 340 | 423 | 292 | 307 | 440 |
| July | 243 | 261 | 318 | 230 | 255 | 255 | 262 | 270 | 413 |
| August | 246 | 274 | 306 | 241 | 267 | 261 | 253 | 285 | 375 |
| September | 260 | 301 | 512 | 257 | 304 | 408 | 264 | 296 | 669 |
| October | 272 | 337 | 794 | 256 | 343 | 832 | 296 | 328 | 737 |
| November | 266 | 333 | 483 | 246 | 341 | 492 | 298 | 321 | 469 |
| December | 253 | 313 | 365 | 235 | 331 | 372 | 281 | 284 | 355 |
| January | 398 | 378 | 399 | 424 | 399 | 400 | 357 | 344 | 398 |
| February | 446 | 437 | 486 | 487 | 477 | 542 | 381 | 376 | 407 |
| March | 370 | 415 | 457 | 395 | 463 | 494 | 331 | 341 | 404 |
| April | 279 | 345 | 365 | 273 | 370 | 375 | 288 | 307 | 349 |
| May | 253 | 276 | 293 | 247 | 282 | 294 | 262 | 267 | 293 |
| June | 230 | 262 | 267 | 226 | 257 | 257 | 236 | 270 | 282 |
1Admissions to all medical treatment facilities, Army and non-Army. Excludes carded-for-record-only cases reported on summary morbidity reports, largely venereal disease cases treated while individual is on duty status.
2Data for June 1960, partially estimated.
Source: Morbidity Report, DD Form 442 (RCS MED-78).
Area | All nonbattle causes | Disease1 | Nonbattle injury1 | ||||||
19602 | 1959 | 1958 | 19602 | 1959 | 1958 | 19602 | 1959 | 1958 | |
Total Army | 11.68 | 12.28 | 13.52 | 9.67 | 9.88 | 11.12 | 2.01 | 2.40 | 2.40 |
Total ZI3 | 14.07 | 14.63 | 15.81 | 11.73 | 11.86 | 12.95 | 2.34 | 2.77 | 2.86 |
Total outside ZI | 8.07 | 8.62 | 10.11 | 6.56 | 6.80 | 8.40 | 1.51 | 1.82 | 1.71 |
1Days lost for disease and nonbattle injury separately were estimated.
2Data for June 1960, partially estimated.
3Includes evacuees from outside ZI.
Source: Morbidity Report, DD Form 442 (RCS MED-78).
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bined noneffective rate was not as great, proportionately, as the decrease in the corresponding admission rate, and so, in total, the decreased rate of incidence of morbidity is more than enough to account for the reduction in the noneffective rate. For the injury component, however, the noneffective rate declined proportionately more than did the injury admission rate thereby indicating also a further reduction in length of stay for such cases. The decreases in noneffective rates occurred both in ZI and outside ZI and in each of the principal oversea areas included in the outside ZI category.
Hospitalization.-There were nearly 30,000 fewer initial admissions of Army personnel to hospitals in fiscal year 1960 than in the preceding year. The rate of initial admissions to hospitals declined from 228.5 per 1,000 to 199.4, a decrease of more than 10 percent. Table 7 shows the numbers of such initial admissions along with the numbers of patients in the census, the daily average number of patients occupying beds, and some information on specific dispositions of hospitalized
[Figures in parentheses are subtotals]
Element of patient flow | 19602 | 1959 | 1958 |
Patient census, beginning of fiscal year | 8,434 | 8,744 | 10,666 |
Admissions (initial)3 | 171,243 | 200,908 | 239,656 |
Final dispositions4 | 171,195 | 201,218 | 241,578 |
| Returned to duty4 | (165,621) | (195,001) | (234,615) |
| Disability retirements | (1,887) | (2,202) | (2,716) |
| Disability separations | (2,042) | (2,273) | (2,294) |
| Other final dispositions | (1,645) | (1,742) | (1,953) |
Patient census, end of fiscal year | 8,482 | 8,434 | 8,744 |
Daily average census | 8,990 | 9,614 | 10,948 |
Daily average occupying beds | 7,430 | 8,219 | 9,543 |
1Includes Army patients occupying beds in VA hospitals who are carried on the rolls of Army hospitals pending discharge for disability. Excludes transient patients; that is, patients remaining in military debarkation hospitals, patients remaining overnight in other military hospitals, and aeromedical-evacuee patients.
2Data for June 1960, partially estimated.
3Includes all direct admissions to hospital for bed care or observation, transfers from dispensary or sick-in-quarters status, readmissions for relapses or sequelae of previously treated conditions, readmission of patients AWOL for more than 10 days' duration, and admissions to ship sick bays while in passenger status at sea.
4Adjusted so that initial admissions plus beginning census equals final dispositions plus end census.
Source: Beds and Patients Report, DD Form 443 (RCS MED-79).
cases. While nearly all the figures in the table decreased from the preceding year's level, the declines in the patient census and beds occupied figures were proportionately considerably less than that in the admissions. This reflects the fact that the earlier years' relative excesses of admissions represented cases of fairly short duration (for example, respiratory disease). When the daily average number of
beds occupied is related to the average strength of Army personnel, it is seen that 0.87 percent of Army active-duty personnel were occupying hospital beds on the average day in fiscal year 1960 as compared with 0.93 percent in fiscal year 1959 and 1.02 percent in fiscal year 1958.
Utilization of hospitals and dispensaries.-The average daily number of beds occupied in fixed Army hospitals worldwide in fiscal year 1960 was 13,078. This is nearly 700 (about 5 percent) less than the previous year's average, 13,741. (Note that the figures given in table 8 of this report and in the corresponding table of previous reports relate to beds infixed hospitals only; they exclude appreciable numbers of beds in nonfixed hospitals, mostly in Korea but some elsewhere, including some at posts in the United States engaged in training activities.) All the decrease in hospital beds occupied results from decreased numbers of active-duty personnel (largely Army) occupying beds. There were slight increases in the average number of dependents occupying beds and also in the category 'other patients,' which includes personnel on active duty for training under the Reserve Forces Act. The increase in the number of military dependents occupying beds continues a trend noted in the earlier reports. It is related in part to increasing numbers of dependents as the proportion of Army personnel married and the number of dependents per married male both increase. Another important factor affecting this trend is the Medicare Program discussed earlier in this report.
During the past fiscal year, one class II hospital (Army and Navy, at Hot Springs, Ark.) was closed as an installation on 1 April 1960. Table 8 shows data on patient census, admissions, and bed occupancy for U.S. Army fixed hospitals separately by area and for class II hospitals by specific hospital.
Table 9 shows data on outpatient visits by category of patient as reported by U.S. Army medical treatment facilities, worldwide, during the past 3 fiscal years. The number of outpatient visits increased by only about 1 percent in fiscal year 1960, with the increase occurring among dependents of military personnel. More than a million outpatient visits were reported in the average month of fiscal year 1960; nearly half of these visits were made by dependents of military personnel, over 40 percent by active-duty military personnel, and the balance by personnel of various other groups as shown in the table.
42-43
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Examination of registrants for military service.-The 174,104 registrants who were given a preinduction examination in fiscal year 1960 represented the smallest number since the passage of the Universal Military Training and Service Act of 1951 (table 10). The total proportion of examinees who did not qualify for military service was somewhat lower than in the preceding year (44.7 percent in fiscal year 1960 versus 46.4 percent in fiscal year 1959). As in the preceding fiscal year, about 5 percent of the examinees were classified as 'Trainability Limited V-O.' The current higher mental standards, effective since early in fiscal year 1959, were designed to eliminate persons of low mental
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46
aptitude. Toward this end, registrants classified on the basis of the AFQT (Armed Forces Qualification Test) as mental group IV, the lowest qualified mental group, are tested additionally by the ACB (Army Classification Battery). Registrants so tested, who fail to attain the required minimum on the ACB, are classified as 'Trainability Limited V-O,' provided they are medically qualified. Though not acceptable now, these registrants would qualify under mobilization or emergency conditions. When compared with fiscal year 1959, the current fiscal year indicates lower disqualification for mental reasons, but higher for medical reasons. This is in all probability due to differences in the distribution of the examinees by State.
The statutory and executive provisions, the medical, mental, and moral standards, and the administrative procedures governing such examinations remained basically unchanged. The Universal Military Training and Service Act, which was to have expired in July 1959, was extended to July 1963 (Public Law 86-4, approved on 23 March 1959). The act originally provided that the minimum medical requirements for acceptability should not be higher than those applied to persons inducted in January 1945, and the passing score on the prevailing mental test should be fixed at the percentile score of 10 points. These provisions were amended by Public Law 85-564 (approved in July 1958), authorizing the President to modify these requirements, except in time of war or national emergency declared by Congress. As a result of this authorization, the current mental requirements were raised; no basic change, however, occurred with respect to the medical requirements.
Compared with the medical fitness standards of World War II, the current standards, as promulgated by AR 40-503, Physical Standards and Physical Profiling for Enlistment and Induction, are more liberal, specifically with respect to psychoneurotics-the underlying philosophy being that greater proficiency can be accomplished with respect to eliminating such persons when they are observed under military conditions. The current change to these regulations (Changes 3, 1959) is primarily administrative and interpretative in nature. These standards, originally confined to enlistment and induction, were made applicable to appointments for commissioned or warrant officers. (Accordingly, the original title of these regulations was changed to 'Standards of Medical Fitness for Appointment, Enlistment, and Induction.') With respect to the interpretation of the standards, the phrase in the original regulations, stating that the standards should be considered with discretion and not construed too strictly or arbitrarily, was deleted. This implies a more rigid interpretation of the standards-a practice which has been in existence since early 1957 when the phrase was suspended by a Department of the Army letter. Simultaneously, the change provided
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for the following modifications: (1) Orthodontic appliances attached to teeth for continued treatment were made disqualifying; (2) minimal intestinal resection in infancy or childhood (for example, intussusception) was made acceptable in certain circumstances; (3) paroxysmal convulsive disorders and disturbances of consciousness (grand and petit mal, psychomotor attacks, and narcolepsy) became
disqualifying, whether or not controlled by medication; and (4) migraine was also made disqualifying when frequent and incapacitating. The change also established corrected (or correctable) distant vision as the only criterion in regard to the standards for distant vision. Corrected (or correctable) distant vision of 20/40 in one eye and 20/70 in the other eye or 20/30 and 20/100 or 20/20 and 20/400 became the minimal visual requirements for acceptability. The profiling on the basis vision was also modified, and now only individuals with 20/20 uncorrected distant vision can be currently graded 1 under E (eyes) in the profile system. (Previously, individuals with a minimum of vision correctable to 20/20 in one eye and 20/30 in the other eye could be so profiled.)
In order to attain maximum uniformity in the interpretation of the medical standards, the orientation courses for physicians assigned to the AFES (Armed Forces examining stations), established in 1957 at the Army Medical Service School, have been continued. Furthermore, to insure optimum use of this trained personnel, the tour of duty of physicians in AFES was generally extended to about 2 years, replacingthe former assignments that averaged about 1 year.
In fiscal year 1960, the Department of Defense issued calls for 87,000 inductees (table 11). This number is about 20 percent less than it was in fiscal year 1959 and 50 percent less than the 175,000 called in fiscal year 1957. About 90,000 registrants were inducted. In addition, the Army procured about 95,000 men through voluntary enlistments.
