Congressional and Veterans Affairs (VA) leaders have recommended the VA become more of a purchaser than a provider of health care. Fee-for-service Medicare provides an example of how purchased care differs from the VA's directly provided care. Using established indicators of overly intensive end-of-life care, we compared the quality of care provided through the two systems to veterans dying of cancer in fiscal years 2010-14. The Medicare-reliant veterans were significantly more likely to receive high-intensity care, in the form of chemotherapy, hospital stays, admission to the intensive care unit, more days spent in the hospital, and death in the hospital. However, they were significantly less likely than VA-reliant patients to have multiple emergency department visits. Higher-intensity end-of-life care may be driven by financial incentives present in fee-for-service Medicare but not in the VA's integrated system. To avoid putting VA-reliant veterans at risk of receiving lower-quality care, VA care-purchasing programs should develop coordination and quality monitoring programs to guard against overly intensive end-of-life care.

IMPORTANCE Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. OBJECTIVE To describe a consensus framework for surgical care designed to respond to this emerging need. DESIGN, SETTING, AND PARTICIPANTS An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. MAIN OUTCOMES AND MEASURES The working group's method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. RESULTS Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. CONCLUSIONS AND RELEVANCE Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.

To identify factors associated with HIV in Botswana, a standardized questionnaire was administered to 135 tuberculosis patients with known HIV status. HIV-positive patients were more likely than HIV-negative patients to: be female (45% vs 26% (adjusted prevalence odds ratio (aPOR)=3.8, 95% confidence interval (CI)=1.1-12.7)); be 26-35 years old (50% vs 19% (aPOR=2.7, CI=0.7-10.7)); be unmarried (91% vs 71% (aPOR=13.3, CI=2.5-72.7)); have higher income (24% vs 10% (aPOR=8.2, CI=1.6-42.9)); report separation from spouse/partner for work (63% vs 52% (aPOR=1.8, CI=0.5-6.2)); have 2 sex partners other than their regular partner (82% vs 67% (aPOR=1.8, CI=0.5-7.5)); and state that they or their partner drank alcohol before sex (77% vs 55% (aPOR=6.8, CI=1.9-24.1)). Only 22% of respondents used condoms during all of their past 10 sexual encounters. These data provide information for HIV prevention strategies.

Key PointsQuestionWhat is the cost associated with National Quality Forum–identified intensive medical services in the last month of life to beneficiaries and to the health care system?FindingsIn this cohort study of 48 937 patients with cancer enrolled in Medicare and the Veterans Health Administration, those receiving no intensive service had a health system cost of $7660, whereas for the 59% of patients receiving 1 or more intensive services in the last month of life, the cost was $23 612. Expected beneficiary costs in the last month of life were $133 for patients with no intensive service and $1257 for patients with at least 1 intensive service.MeaningDespite recommendations, more than half of patients with cancer receive intensive services at the end of life at a substantial cost to beneficiaries and the heath system.