Health on the Homefront:

Health on the Homefront: Formation of a Wounded, Ill, and Injured Registry for USN and USMC Service Members Dagny Magill, MPH, Epidemiologist Deployment Health Division, Epidemiology Data Center Department (EDC), Navy and Marine Corps Public Health Center, Department of the Navy ACKNOWLEDGEMENTS: Tina M. Luse, MPH (EDC Deployment Division Head, Epidemiologist) Patricia Miller, MPH (Former EDC ORISE Fellow Epidemiologist) DISCLAIMER: The views expressed in this session are those of the presenter(s) and do not necessarily reflect the official policy or position of the U.S. Government or the Commonwealth of Virginia. The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U. S. Government. CONFLICT OF INTEREST DISCLOSURE: Dagny Magill, MPH has no real or apparent conflicts of interest to report. Navy and Marine Corps Public Health Center 1 1

Objectives A) Explain the purpose of identifying wounded, ill, and injured service members. B) Describe how the wounded, ill, and injured service member is identified using administrative medical encounter record databases. C) Describe results and the registry. Navy and Marine Corps Public Health Center 2 Background The Wounded, Ill, and Injured Program (WII) strategic goals: Expand Access to Care Improve Quality of Care Performance Enhancement Support Transition and Coordination of Care Improve Screening and Surveillance Navy and Marine Corps Public Health Center 3 2

Background WII Programs are involved with: Active living Preventing drug abuse and excessive alcohol use Pain management Healthy eating Chronic illness Reproductive and sexual health Injury and violence free living Psychological and emotional well-being Navy and Marine Corps Public Health Center 4 http://www.med.navy.mil/sites/nmcphc/health-promotion/pages/default.aspx Relax, Relax- available at: http://www.med.navy.mil/sites/nmcphc/health-promotion/psychological-emotional-wellbeing/relax-relax/pages/index.html Navy and Marine Corps Public Health Center 5 3

Background Navy and Marine Corps Public Health Center 6 Background Navy and Marine Corps Public Health Center 7 4

Purpose Out of concern for the healthcare, support, treatment, and rehabilitation of injured service members deployed in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), a registry was developed. Registry would list WII service members with signature injuries. Make the registry accessible to each Navy Military Treatment Facility (MTF) to allow healthcare providers to follow up with their WII patients on treatment. Navy and Marine Corps Public Health Center 8 Mental Health Disorders Risk factors: young, singer personnel, lower socioeconomic status, enlisted rank, length of service, number of deployments 1 9-19% of service members returning from deployment report a behavioral health problem 2 10% of total hospitalization included a diagnosis of a behavioral health disorder 3 Service members who screen positive for behavioral health disorder are significantly more likely to leave the service early 2 1. Riddle, J.R., T.C. Smith, T.E. Corbeil, et. al (2007). Millennium cohort: The 2001-2003 baseline prevalence of mental disorders in the US military. Journal of Clinical Epidemiology, 60: 192-201. 2. Hoge, C.W., J.L. Auchterlonie, C.S. Milliken (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan, JAMA, 295(9): 1023-1032. 3. Wojcik, B.E., F.Z. Akhtar, L.H. Hassell (2009). Hospital admissions related to mental disorders in US Army soldiers in Iraq and Afghanistan, Military Medicine, 174 (10): 1010-1021. Navy and Marine Corps Public Health Center 9 5

Post-traumatic Stress Disorder (PTSD) Positive PTSD ranges of 5-13% in soldiers surveyed 1 Of those with PTSD, 56% reported using mental health services 2 Major Depressive Disorder (MDD) MDD in the military: US Army (5.5%), US Air Force (3.3%), US Navy (2.4%), US Marine Corps (1.7%) 4 25% of those with major depression also had a substance use disorder 4 1. Wojcik, B.E., F.Z. Akhtar, L.H. Hassell (2009). Hospital admissions related to mental disorders in US Army soldiers in Iraq and Afghanistan, Military Medicine, 174 (10): 1010-1021. 2. Erbes, C., J. Westermeyer, B. Engdahl, E. Johnsen (2007). Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan, The Society of Federal Health Professionals, 172(4): 359-363. 3. Yu-Chu Shen, PhD; Jeremy Arkes, PhD; and Thomas V. Williams, PhD (2012). Effects of Iraq / Afghanistan Deployments on Major Depression and Substance Use Disorder: Analysis of Active Duty Personnel in the US Military American Journal of Public Health, Supplement 1, 2012 Vol. 102. No. S1 Navy and Marine Corps Public Health Center 10 Alcohol use disorder (AUD) 12.6% of military in a sampled cohort had an alcohol abuse behavioral health disorder 1 Problematic drinking levels as high as 33% 2 Only 18% of those screening positive for alcohol abuse reported using services 2 1. Riddle, J.R., T.C. Smith, T.E. Corbeil, et. al (2007). Millennium cohort: The 2001-2003 baseline prevalence of mental disorders in the US military. Journal of Clinical Epidemiology, 60: 192-201. 2. Erbes, C., J. Westermeyer, B. Engdahl, E. Johnsen (2007). Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan, The Society of Federal Health Professionals, 172(4): 359-363. Navy and Marine Corps Public Health Center 11 6

Suicide and related conditions Active service members (SMR 1.33, 95% CI:1.03-1.69) and those with a behavioral disorder (SMR 1.77, 95% CI: 1.01-2.87) have a increased risk of suicide 1 2.2% of service members reported they attempted suicide in 2008, compared to just 0.8% in 2005 2 2,990 service members died by suicide while on active duty from 1998-2011 3 1. Kang, H.K., T.A. Bullman (2008). Risk of suicide among US Veterans after returning from the Iraq or Afghanistan war zones. JAMA, 300(6): 1-2. 2. Bray, R.M., M.R. Pemberton, M.E. Lane et al. (2010). Substance use and mental health trends among U.S. Military active duty personnel: key findings from the 2008 DoD Health Behavior Survey. Military Medicine, 175(6): 390. 3. MSMR (2012). Deaths by suicide while on active duty, active and reserve components, U.S. Armed Forces, 1998-2011.MSMR 19(6): 7. Navy and Marine Corps Public Health Center 12 Injuries ~21% of individuals evacuated from OEF/OIF were due to non-hostile injuries 1 In 2009, there were over 27,000 TBIs in the US Military, with over 75% of them classified as mild 2 ~23% soldiers may have suffered form some form of TBI 3,4 From 2001-2006 there were approximately 8,000 military amputations 87.9% due to explosive devices 5 1. Fischer, H. (2010). U.S. Military casualty statistics: Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom. Congressional Research Service Report for Congress. 2. MSMR (2012). Deaths by suicide while on active duty, active and reserve components, U.S. Armed Forces, 1998-2011.MSMR 19(6): 7. 3. Hoge, CW, D McGurk, JL Thomas, et al. (2008). Mild traumatic brain injury in U.S. Soldiers returning from Iraq, New England Journal of Medicine, 358(5): 453-463.KE Powell, LA Fingerhut, CM Branche, and DM Perotta (2000). Deaths due to injury in the military. American Journal of Preventive Medicine, 18(3): 26-32. 4. Terrio, H., Brenner, L. A., Ivins, B. J., Cho, J. M., Helmick, K., Schwab, K., et al. (2009). Traumatic Brain Injury Screening: Preliminary Findings in a US Army Brigade Combat Team. The Journal of Head Trauma Rehabilitation, 21 (1), 14-23. 5. Stansbury, L.G., S.J. Lalliss, J.G. Branstetter et al. (2008). Amputations in U.S. Military personnel in the current conflicts in Afghanistan and Iraq. Journal of Orthopedic Trauma, 22(1): 43-46. Navy and Marine Corps Public Health Center 13 7

Development Developed WII methodology working group Epidemiologists Subject matter experts International Classification of Diseases, 9 th Revision, Clinical Modification (ICD-9-CM) coders Case management and nursing representatives Developed case definition for each condition of concern using ICD-9- CM codes. Developed general rules Navy and Marine Corps Public Health Center 14 Methods Analysis was completed for all active duty and reserve United States Marine Corps (USMC) and United States Navy (USN) service members as long as they are currently in the military. Deployment records from the Contingency Tracking System were used to identify previous deployments. All medical encounter records were identified from ambulatory and inpatient records and used to collect ICD-9-CM codes. Navy and Marine Corps Public Health Center 15 8

Methods Conditions of Concern: Inpatient Outpatient Days from deployment Major depressive disorder (MDD) 1 2 730 Post-traumatic stress disorder (PTSD) 1 2 730 Alcohol use disorder (AUD) 1 2 730 Suicide, suicide ideation, and self-inflicted injury 1 1 730 Traumatic brain injury (TBI) 1 1 365 Amputation 1 1 365 Other physical injury (Injury) 1 1 90 Navy and Marine Corps Public Health Center 16 Methods WII Registry only identifies conditions in which encounters occurred after the last recorded deployment Deployment begin date Deployment return date* Maximum allowed days between deployment return date and date of first encounter All encounters for conditions of interest captured * If unknown, the average of 210 days was used Navy and Marine Corps Public Health Center 17 9

The WII Registry, Example Active Duty ID Last Name First Name Date of Birth Service Deployment Depl. Begin Location date FY of 1st Depl. End ICD9, UIC FMP PatCat WII date PTSD Encounter Date of ICD9, ICD9, ICD9, ICD9, ICD9, ICD9, most PTSD AUD MDD Suicide Ampt Injury TBI DMIS ID AUD MDD suicide ampt injury TBI recent encounter Active Duty XXX XX Smith John 5/1/1972 Navy Sea 1/1/2012 4/1/2012 234 20 N11 2012 495.2 YES 2013 2356 Reserve XXX XX Lawton Bob 8/23/1986 Marine Iraq 5/7/2011 9/1/2011 845 20 M13 2012 956.2 456.2 YES YES 2013 7952 Active Duty XXX XX Active Duty XXX XX Active Duty XXX XX Active Duty XXX XX Swatch Jerry 12/5/1982 Navy Afghanistan 1/1/2012 4/1/2012 678 20 N11 2013 894.2 567.9 YES YES 2012 1456 Pather Rick 3/5/1969 Navy Afghanistan 2/9/2010 6/1/2010 215 20 N11 2010 3472 YES 2013 1236 Richards Peter 7/22/1988 Marines Bahrain 5/8/2009 9/2/2009 568 20 M11 2010 6790 YES 2010 6548 Howard Jackie 12/9/1985 Navy Sea 7/2/2013 8/3/2013 245 20 N11 2013 6789 YES 2013 23123 Reserve XXX XX Blithers Sara 3/7/1982 Navy Iraq 2/9/2010 6/1/2010 15 20 N13 2011 789.5 YES 2012 2156 Active Duty XXX XX Active Duty XXX XX Active Duty XXX XX Lawser Billy 7/4/1983 Marines Iraq 7/2/2013 8/3/2013 5 20 M11 2013 567.9 YES 2013 8569 Ader Teak 8/4/1985 Marines Bahrain 5/8/2009 9/2/2009 689 20 M11 2010 456.7 908.6 234.8 YES YES YES 2013 1456 Chatway Larry 10/10/1987 Marines Afghanistan 2/9/2010 6/1/2010 215 20 M11 2010 657.6 YES 2011 8953 Reserve Pray Michael 11/15/1985 Navy Sea 2/9/2010 6/1/2010 56 20 N13 2011 456.7 YES 2013 2456 Navy and Marine Corps Public Health Center 18 The WII Registry, Example Active Duty ID Last Name First Name Active Duty XXX XX XXX XX Date of Birth Service Smith John 5/1/1972 Navy Sea Deployment Location Deployment Begin Date Deployment End Date UIC FMP PatCat 1/1/2012 4/1/2012 234 20 N11 2012 FY of 1st WII Encounter ICD9, PTSD ICD9, AUD ICD9, MDD ICD9, suicide ICD9, amputations ICD9, injury ICD9, TBI PTSD AUD MDD Suicide Amputations Injury TBI Date of most DMIS recent ID encounter 309.81 YES 2013 2356 Navy and Marine Corps Public Health Center 19 10

Results Table 1: Average age and days between date of deployment ended to first encounter for WII Registry members, by service Service Average age (yrs) Avg. # of days between date deployment ended to first encounter All Military Treatment Facilities USMC 28.0 425.2 (1.2 years) USN 31.7 440.1 (1.2 years) Virginia Military Treatment Facilities USMC 31.3 492.4 (1.4 years) USN 31.2 441.9 (1.3 years) Navy and Marine Corps Public Health Center 20 Results Table 2: Deployment location of WII Registry members, by service Location of Deployment USMC USN Afghanistan 7,961 2,147 Bahrain 75 904 Djibouti 22 228 Iraq 2,518 1,106 Kuwait 429 502 Kyrgyzstan 221 21 Qatar 0 166 Serbia/Yugoslav 0 48 Sea 0 4,744 Others/Unknown 125 344 Navy and Marine Corps Public Health Center 21 11

Results Table 3: Signature wounds of WII Registry service members, by service Service Any* PTSD MDD Suicide AUD TBI Amputation Injury USMC 11,351 22.7% 22.4% 4.3% 20.9% 24.7% 1.2% 3.9% USN 10,210 16.9% 38.6% 7.7% 25.2% 10.5% 0.5% 0.6% Total 21,561 20.1% 29.5% 5.8% 22.8% 18.4% 0.9% 2.5% * Any of the seven conditions Suicide, suicide ideation, and self-inflicted injuries Alcohol use disorder Fractures, dislocations, internal injuries, burns, open wounds, crushing injuries, superficial injuries, poisoning, and contusions. Navy and Marine Corps Public Health Center 22 Results Table 4: Signature wounds of WII Registry service members, by service and component USMC Any* PTSD MDD Suicide AUD TBI Amputation Injury Active Duty 6,866 20.6% 20.3% 5.1% 24.6% 26.2% 0.4% 2.7% Reserves 4,485 23.9% 23.6% 3.8% 18.7% 23.8% 1.6% 4.6% USN Any* PTSD MDD Suicide AUD TBI Amputation Injury Active Duty 7,715 17.1% 39.4% 7.3% 24.4% 10.5% 0.6% 0.7% Reserves 2,495 4.6% 44.3% 8.8% 28.9% 12.0% 0.6% 0.7% * Any of the seven conditions Suicide, suicide ideation, and self-inflicted injuries Alcohol use disorder Fractures, dislocations, internal injuries, burns, open wounds, crushing injuries, superficial injuries, poisoning, and contusions. Navy and Marine Corps Public Health Center 23 12

Results Table 5: Signature wounds of WII Registry service members, by Navy Medicine Region Region PTSD MDD TBI Amputation Suicide AUD Injury All 20.1% 29.5% 18.4% 0.9% 5.8% 22.8% 2.5% Navy Medicine East Navy Medicine West Navy Medicine Capital 19.4% 29.4% 18.7% 0.5% 6.4% 23.7% 1.9% 20.2% 29.5% 17.8% 0.8% 5.7% 23.6% 2.5% 25.2% 32.3% 15.8% 0.4% 3.8% 20.4% 2.2% Other 21.1% 29.6% 20.5% 2.9% 4.1% 16.7% 5.1% Suicide, suicide ideation, and self-inflicted injuries Alcohol use disorder Fractures, dislocations, internal injuries, burns, open wounds, crushing injuries, superficial injuries, poisoning, and contusions. Navy and Marine Corps Public Health Center 24 Figure 1: Virginia Military Treatment Facilities Navy and Marine Corps Public Health Center 25 13

Results in Virginia Table 6: Signature wounds of WII Registry service members in Virginia, by service Service Any* PTSD MDD Suicide AUD TBI Amputation Injury USMC 493 27.0% 28.0% 2.9% 15.0% 20.9% 0.7% 5.4% USN 2,662 10.6% 38.9% 12.1% 27.8% 9.7% 0.4% 0.6% Total 3,155 13.4% 37.0% 10.5% 25.6% 11.7% 0.5% 1.4% * Any of the seven conditions Suicide, suicide ideation, and self-inflicted injuries Alcohol use disorder Fractures, dislocations, internal injuries, burns, open wounds, crushing injuries, superficial injuries, poisoning, and contusions. Navy and Marine Corps Public Health Center 26 Results in Virginia Table 7: Signature wounds of WII Registry service members in Virginia, by service and component USMC Any* PTSD MDD Suicide AUD TBI Amputation Injury Active Duty 386 28.1% 28.4% 3.0% 13.8% 20.4% 0.5% 5.8% Reserves 107 13.2% 15.6% 1.6% 11.5% 54.7% 0.8% 2.5% USN Any* PTSD MDD Suicide AUD TBI Amputation Injury Active Duty 1987 10.7% 40.1% 11.5% 26.9% 9.5% 0.5% 0.8% Reserves 675 10.1% 35.3% 13.8% 30.3% 10.3% 0.2% 0.0% * Any of the seven conditions Suicide, suicide ideation, and self-inflicted injuries Alcohol use disorder Fractures, dislocations, internal injuries, burns, open wounds, crushing injuries, superficial injuries, poisoning, and contusions. Navy and Marine Corps Public Health Center 27 14

Results in Virginia Table 8: Cases in Virginia MTFs, by service Service Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Facility 6 Facility 7 All others USMC 88 14 11 179 1 58 7 135 USN 1,556 458 210 25 160 40 58 141 Total 1,644 472 221 204 161 98 65 276 Navy and Marine Corps Public Health Center 28 Results in Virginia Table 9: Ranking of conditions, by service Rank USMC (all) USMC in Virginia USN (all) USN in Virginia 1 st TBI MDD MDD MDD 2 nd PTSD PTSD AUD AUD 3 rd MDD TBI PTSD Suicide 4 th AUD AUD TBI PTSD 5 th Suicide Injuries Suicide TBI 6 th Injuries Suicide Injuries Injuries 7 th Amputations Amputations Amputations Amputations Suicide, suicide ideation, and self-inflicted injuries Alcohol use disorder Fractures, dislocations, internal injuries, burns, open wounds, crushing injuries, superficial injuries, poisoning, and contusions. Navy and Marine Corps Public Health Center 29 15

Results Table 10: Case management cases by service Service Individuals in Case Management MTFs (all) % of Cases USMC 3,542 31.2% USN 1,922 18.8% MTFs (Virginia) USMC 201 40.8% USN 370 13.9% Navy and Marine Corps Public Health Center 30 Discussion Difference between USMC, USN, active duty and reserve populations Comorbidity of conditions Average length of time between when a service member returns from deployment to when a condition is identified is over a year A lower percentage of USN are in case management compared to USMC Navy and Marine Corps Public Health Center 31 16

Limitations These data do not include patients in theater or shipboard or who were seen in a purchased care facility. There is a reporting lag between the time a personnel record is created in DMDC (both the roster and CTS files) and the date the data are received at the EDC. Using the average length of deployment of 210 days to estimate deployment end dates may over- or under-estimate service members case status. Navy and Marine Corps Public Health Center 32 Limitations Only Navy and Marine Corps data are available for analysis so results may not be appropriate for other population comparison. Reporting of medical encounters is dependent on correct ICD-9-CM coding practices. Data for medical surveillance are considered provisional and medical case numbers may change between the time the report is created and distributed. Navy and Marine Corps Public Health Center 33 17

Current Applications Methodology was used in the formation of a WII Registry for the Navy Expeditionary Combat Command personnel. Data from registry is frequently used in quickly assessing WII population statistics. Increased dissemination to MTFs, healthcare personnel, and improved medical care for WII personnel. Navy and Marine Corps Public Health Center 34 Contact Information Dagny Magill dagny.magill.ctr@med.navy.mil 757.953.0876 EpiData Center Department Navy and Marine Corps Public Health Center 620 John Paul Jones Circle, Suite 1100 Portsmouth, VA 23708 757.953.0700 35 18