Defense Date


Document Type


Degree Name

Doctor of Philosophy


Health Administration

First Advisor

Dolores Clement


The prolonged wars in Iraq and Afghanistan have taken a toll on the United States as a whole and the United States military in particular. The primary aim of this research is to determine what impact the wars in Iraq and Afghanistan have had on the performance of military hospitals over the fiscal years 2001-2006. Specifically, what direct effect has the war in Iraq and Afghanistan had on the productivity and quality of military hospitals, and, do productivity and quality trends differ based on hospital characteristics? Since observations over multiple time periods are nested within hospitals, multilevel mixed effects regression and Poisson regression models are used to evaluate changes in productivity and quality while accounting for differences within hospitals. Using a contingency theory framework, this study fills the gap in looking at the impact of war on permanent military hospitals’ productivity and quality using nationally developed and implemented quality indicators (Agency for Healthcare Quality and Research Inpatient Quality Indicators and Patient Safety Indicators). Structural characteristics of the hospital, teaching status and branch of Armed Service influenced productivity and certain quality indicators. The structural components were not able to reliably predict differences in productivity and all quality indicators, but overseas hospitals and non-teaching hospitals were most likely to differ from major teaching hospitals. The wars in Iraq and Afghanistan, denoted by the variables for wounded discharges and deployed staff, were only partially related to the productivity of military hospitals. Only an increase in the percentage of wounded discharges was related to productivity of military hospitals, and none were related to the quality indicators. In essence, the war affected the workload and productivity of military hospitals, but it did not affect the quality provided in the hospitals, as measured by AHRQ inpatient and patient safety quality indicators. Structural characteristics account for more of the variation in quality among military hospitals than the impact of war within the timeframe studied.


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Date of Submission

August 2013