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Mission Critical: Understanding Force/Fleet Readiness through Health Data
Health on the Homefront:
Tina Luse, MPH, Epidemiologist Deployment Health Division, Epidemiology Data Center Department (EDC),
Navy and Marine Corps Public Health Center, Department of the Navy
Co-Authors:
– Dagny Magill, MPH (EDC Epidemiologist)
– Christine E. Glasheen, MPH (EDC Epidemiologist)
Acknowledgments
– Kevin Aldrich, Serah Iheasirim, Patricia Miller, Beth Poitras, Jennifer Phillips, Michelle Barnes, Viann Nguyen, Natasha Burns, Danielle Wallack, Jean Slosek, Desmond Bibio, Dr. Christopher Rennix
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:
All authors have no real or apparent conflicts of interest to report.
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Presentation Outline
– Introduction to the EpiData Center Department
– History and creation of the Force/Fleet Health Surveillance Report (FHSR)
– Methodology
– FHSR example
– Data limitations
– FHSR related project and future considerations
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EpiData Center (EDC)
Created in 2005 Provides epidemiologic services to Department of the Navy customers 4 product lines:
– Communicable Disease
– Clinical Epidemiology
– Occupational/Environmental Epidemiology
– Deployment Health IT Division
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Data Sources
Defense Manpower Data Center (DMDC)
– Active duty, reserve, Contingency Tracking System (CTS)
Standard Inpatient Data Record (SIDR)
Standard Ambulatory Data Record (SADR) & Comprehensive Ambulatory/Professional Encounter Record (CAPER)
Electronic Health Record (AHLTA) Theater Medical Data Store
(TMDS)
Health Level 7 (HL7)
– Inpatient/outpatient pharmacy, microbiology, chemistry, anatomic pathology, radiology
Electronic Deployment Health Assessment (eDHA)
– Pre-deployment Health Assessment (pre-DHA)
– Post-deployment Health Assessment (PDHA)
– Post-deployment Health Reassessment (PDHRA)
– Mental Health Assessments (MHAs)
Navy and Marine Corps Public Health Center
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From the Front Page to a Command Question
“US Soldiers Face Host of Mental Health Issues” – US News and World Report. Jan 25, 2012
“Prescription Drug Abuse, Overdoses Haunt Veterans Seeking Relief from Physical, Mental Pain”- USA Today. Jan 25, 2011
“US Marines Remain Focused on Preventing Suicides: General”-Reuters. Aug 28, 2012
“Baffling Rise in Suicides Plagues US Military” – New York Times. May 15, 2013
Navy and Marine Corps Public Health Center
The Force/Fleet Health Surveillance Report (FHSR)
Created 2012 Comprehensive report:
– Outpatient behavioral health encounters– Depression– Alcohol abuse and dependence– Post-traumatic stress disorder (PTSD)– Suicide ideation– Traumatic brain injury (TBI)– Extended medication use– eDHA screening for alcohol abuse, PTSD, major depressive
disorder (MDD), and suicide/homicide risk
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The Force Health Surveillance Report (FHSR)
Prepared monthly 13-month reporting timeframe Updates information for complete reporting period each month
Navy and Marine Corps Public Health Center
Customers
Current customers:
– USMC
• Marine Expeditionary Forces (MEF I, II, III)
• Marine Special Operations Command (MARSOC)
• Reserves (MARFORRES)
– USN
• Naval Expeditionary Combat Command (NECC)
• Naval Special Warfare Command (NSWC)
• Submarine Fleet Forces
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FHSR Structure
Monthly report contains:
– Executive Summary
– Purpose
– Methods
– Results
• Tables and figures
• Individual command structure results
– Discussion
– Limitations
– Appendices
Navy and Marine Corps Public Health Center
Methodology Overview
DMDC
CTS
Ambulatory Encounters
(Direct/Theater)
All Behavioral Health
PTSD
Depressive Disorder
Alcohol AbuseTBI
Suicide Ideation
SIDR
Inpatient (Direct/Theater)
Suicide Ideation
HL7
Outpatient Pharmacy
Extended Medication Use
EDHA
Post Deployment Health Reassessment
PTSD, Alcohol, Depression, Suicide
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Methodology Overview
DMDC
CTS
Ambulatory Encounters
(Direct/Theater)
All Behavioral HealthPTSD
Depressive DisorderAlcohol Abuse
TBISuicide Ideation
SIDR
Inpatient (Direct/Theater)
Suicide Ideation
HL7
Outpatient Pharmacy
Extended Medication Use
EDHA
Post Deployment Health Reassessment
PTSD, Alcohol, Depression, Suicide
Navy and Marine Corps Public Health Center
Methodology: Roster and Deployment History
Population identification– DMDC active duty and reserve
Deployment history – CTS
– Deployment definition: returned from deployment of at least 30 days boots on ground during 210 days prior to report timeframe
Jun 2013 Feb 2014 Mar 2014
210 days
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Methodology Overview
DMDC
CTS
Ambulatory Encounters
(Direct/Theater)
All Behavioral HealthPTSD
Depressive Disorder
Alcohol AbuseTBI
Suicide Ideation
SIDR
Inpatient (Direct/Theater)
Suicide Ideation
HL7
Outpatient Pharmacy
Extended Medication Use
EDHA
Post Deployment Health Reassessment
PTSD, Alcohol, Depression, Suicide
Navy and Marine Corps Public Health Center
Methodology: Encounter Records
Conditions:– Behavioral health, Depressive disorder (DD), Alcohol abuse and
dependence, and PTSD Case definition
– Two or more outpatient encounters on separate days within previous 12 months with at least one visit during the month of interest
– Counted each month of report where definition is met
Feb 2013 Feb 2014 Mar 2014
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Methodology: Encounter Records
Condition– TBI
Case definition– At least one TBI outpatient, inpatient, or theater encounter within
previous 12 months
– TBI is counted once in month of incidence.
– NOTE: ONLY INCIDENT CASES OF TBI INCLUDED
Feb 2013 Feb 2014 Mar 2014
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Methodology: Encounter Records
Condition– Suicide ideation
Case definition– At least ONE outpatient or inpatient visit during report timeframe
– Counted each month of report where definition is met
Feb 2013 Feb 2014 Mar 2014
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Methodology Overview
DMDC
CTS
Ambulatory Encounters
(Direct/Theater)
All Behavioral HealthPTSD
Depressive Disorder
Alcohol AbuseTBI
Suicide Ideation
SIDR
Inpatient (Direct/Theater)
Suicide Ideation
HL7
Outpatient Pharmacy
Extended Medication Use
EDHA
Post Deployment Health Reassessment
PTSD, Alcohol, Depression, Suicide
Navy and Marine Corps Public Health Center
Methodology: Extended Medication Use
Included medication classes
– Antidepressants
– Anxiolytics
– Atypical antipsychotics
– Pain
– Sleep Aids
– Selective Serotonin Reuptake Inhibitors (SSRIs)
– Stimulants
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Methodology: Extended Medication Use
Case definition– At least two new or refill prescriptions or more than 30 pills
dispensed during the 90 days preceding the report period, with at least one prescription dispensed during the report timeframe
– Counted each month of report where definition is met
November 2013 Feb 2014 Mar 2014
Navy and Marine Corps Public Health Center
Methodology Overview
DMDC
CTS
Ambulatory Encounters
(Direct/Theater)
All Behavioral HealthPTSD
Depressive Disorder
Alcohol AbuseTBI
Suicide Ideation
SIDR
Inpatient (Direct/Theater)
Suicide Ideation
HL7
Outpatient Pharmacy
Extended Medication Use
EDHA
Post Deployment Health Reassessment
PTSD, Alcohol, Depression, Suicide
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Methodology: eDHA Deployment Cycle
Member/unit notified to
deploy
Deployment starts
Member completes Pre-
Deployment Health
Assessment
120 days
Deployment ends
30 days 30 days
Member completes Post
Deployment Health
Assessment
90-180 days
Member completes Post
Deployment Health
Reassessment
At least 30 days, “boots on the ground”
Pre-Deployment Phase Post-Deployment PhaseDeployment Phase
Navy and Marine Corps Public Health Center
Methodology: PDHRA PTSD
13. Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month you…
a) Have had nightmares about it or thought about it when you did not want to?
b) Tried hard not to think about it or went out of your way to avoid situations that remind you of it?
c) Were constantly on guard, watchful or easily startled?
d) Felt numb or detached from others, activities, or your surroundings?
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Methodology: PDHRA MDD
14. Over the LAST 2 WEEKS, how often have you been bothered by the following problems:
a) Little interest or pleasure in doing things
b) Feeling down, depressed, or hopeless
Responses: Score:
Not at all 0
Few or several days 1
More than half the days 2
Nearly every day 3
Navy and Marine Corps Public Health Center
Methodology: PDHRA Alcohol Abuse
12a. How often do you have a drink containing alcohol?Never (0) 2-3 times per week (3)Monthly or less (1) 4+ times a week (4)2-4 times a month (2)
12b. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2 (0) 7 to 9 (3)3 or 4 (1) 10 or more (4)5 or 6 (2)
12c. How often do you have six or more drinks on one occasion?Never (0) Weekly (3)Less than monthly (1) Daily or almost daily (4)Monthly (2)
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Methodology: PDHRA Suicide/Homicide Risk
13. Over the PAST MONTH, have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?
– Follow up questions:• How often have you been bothered by these thoughts?
• Have you thought about how you might actually hurt yourself?
• How likely do you think it is that you will act on these thoughts about hurting yourself or ending your life over the next month?
• Is there anything that would prevent or keep you from harming yourself? Have you ever attempted to harm yourself in the past?
Navy and Marine Corps Public Health Center
FHSR Output: Deployed End Strength
Group Subgroup Deployed Status* Active Duty Reserve Total
A
1Not Recently Deployed 14,894 5 14,899
Recently Deployed 1,195 0 1,195
2Not Recently Deployed 5,145 0 5,145
Recently Deployed 492 0 492
3Not Recently Deployed 11,063 0 11,063
Recently Deployed 1,088 0 1,088
4Not Recently Deployed 2,909 14 2,923
Recently Deployed 323 2 325
TOTAL
Not Recently Deployed 34,011 19 34,030
Recently Deployed 3,098 2 3,100
GRAND TOTAL 37,109 21 37,130
Navy and Marine Corps Public Health Center
* Recently deployed: returned from a deployment within the past 210 days; Not recently deployed: did not return from a
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FHSR Output: Prevalence of Behavioral Health
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FHSR Output: Prevalence of Health Conditions
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FHSR Output: Behavioral Health
Outpatient Encounters
Behavioral Health PTSD* Depressive Disorder Alcohol
Group Subgroup Deployed Status** Frequency Prevalence*** Frequency Prevalence*** Frequency Prevalence*** Frequency Prevalence***
A
1Not Recently Deployed 422 28.3 125 8.39 112 7.52 108 7.25
Recently Deployed 31 25.9 3 2.51 5 4.18 7 5.86
2Not Recently Deployed 259 50.3 56 10.9 59 11.5 40 7.77
Recently Deployed 23 46.7 3 6.1 1 2.03 2 4.07
3Not Recently Deployed 348 31.5 50 4.52 100 9.04 49 4.43
Recently Deployed 23 21.1 2 1.84 6 5.51 2 1.84
4Not Recently Deployed 107 36.8 37 12.7 33 11.3 17 5.84
Recently Deployed 9 27.9 1 3.1 2 6.19 1 3.1
TOTAL
Not Recently Deployed 1,136 33.4 268 7.88 304 8.94 214 6.29
Recently Deployed 86 27.8 9 2.91 14 4.52 12 3.87
GRAND TOTAL 1,222 32.9 277 7.46 318 8.57 226 6.09
*Currently under care for PTSD **Recently deployed: returned from a deployment within the past 210 days/Not recently deployed: did not return from a deployment within the past 210 days
***Per 1,000 USMC Service Members
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FHSR Output: Incidence of Extended Drug Use
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FHSR Output: PDHRA Screening Results
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Discussion
Synthesize results output
– Were observed differences meaningful
– Identify notable changes across the report period
Highlights presented in Executive Summary at start of report
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Data Limitations
Does not include purchased care facilities. Incomplete/outdated list to identify Sailors and Marines Data lag in DMDC/CTS Accurate International Classification of Disease, 9th Revision, Clinical
Modification (ICD-9-CM) codes eDHA contains self-reported information and does not reflect
diagnoses. Pharmacy data only describe prescriptions, not compliance.
Navy and Marine Corps Public Health Center
FHSR Impact
Reports provide a snapshot of command health. Identifies areas for further analysis
– MFR request to receive analysis of TBI on PDHA Reports created for smaller units upon request
– 7th MAR
– Construction Battalion Customers have provided positive feedback Annual FHSR
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New Feature – Conditions among Currently Deployed
Case definition– Identify service members who are currently deployed to CENTCOM,
using theater medical data, determine the number of members with specific conditions of interest.
– Modified ESSENCE syndromic categories
– Deployments are based on most recent CTS roster
– Includes only a snapshot of current deployers. Does not identify trends over 13-month timeframe.
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Currently Deployed Mar 2014
New Feature - Output
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FHSR Annual Report Output
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FHSR Annual Report Output
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FHSR Annual Report Output
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FHSR Annual Report Output
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FHSR Annual Report Output
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FHSR Annual Report Output
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FHSR Next Steps
Include out of network prescriptions Expand examined conditions
– Sleep disorders Analyze long-term trends Improve unit listings
Navy and Marine Corps Public Health Center
Photographs from: http://static.howstuffworks.com/gif/navy-seal-1.jpg http://upload.wikimedia.org/wikipedia/commons/3/36/Browning_M2HB_USMC.jpg http://www.nydailynews.com/img/2009/07/03/alg_marine_helicopter.jp http://www.konstipation.com/stuff/yank/eod/Navy_EOD2.jpg http://media.dma.mil/2013/Jul/09/2000029028/-1/-1/0/130620-M-5160M-245.JPG http://www.navy.mil/management/photodb/photos/070825-N-9769P-301.jpg http://www.public.navy.mil/surfor/ccsg5/Pages/GeorgeWashingtonReturnstoYokosukaf
orMid-PatrolBreak.aspx http://www.marines.mil/Photos.aspx?igphoto=254135
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Questions?
CONTACT INFORMATIONEpiData Center
Navy and Marine Corps Public Health Center (NMCPHC)620 John Paul Jones Circle, Suite 1100
Portsmouth, VA 23708 Phone: 757-953-0955, DSN: 377
http://www.med.navy.mil/sites/nmcphc/epi-data-center/Pages/default.aspx
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Supplemental Slides
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Methodology
Included ICD-9-CM codes– Behavioral health identification (including tobacco)
• 290-317
– Depressive Disorder• 296.2, 296.3, 296.5, 296.9, 296.90, 296.99, 300.4, 311
– Alcohol Abuse and Dependence• 291.0-291.3, 291.50, 291.80, 291.90, 303.00-303.03, 303.90-303.93, 305.00-
305.00-305.03
– PTSD• 309.81
– Suicide Ideation• V62.84
Navy and Marine Corps Public Health Center
Methodology - TBI
Included ICD-9-CM codes
TBI ICD-9-CM Codes
310.2 907.0
800.0x - 801.9x 950.1 - 950.3
803.0x - 804.9x 959.1
850.x V15.52V15.52_0 - V15.52_9
851.0x - 852.5x V15.52_A - V15.52_F
853.0x - 853.1x V15.5_1 - V15.5_9V15.5_A - V15.5_F
854.0x - 854.1x V15.59_1 - V15.59 9V15.59_A - V15.59_F
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Methodology: Extended Medication Use
Extended medication identificationDrug Classification Drugs included
Antidepressants Amitriptyline, Bupropion, Lithium, Mirtazapine, Nefazodone, Nortriptyline, Trazodone
Anxiolytics Alprazolam, Buspirone, Chlordiazepoxide, Clonazepam, Diazepam, Lorazepam
Atypical Antipsychotics Aripiprazole, Asenapine, Clozapine, Iloperidone, Lurasidone, Olanzapine, Paliperidone, Quetiapine, Risperidone, and Ziprasidone.
Pain Acetaminophen with codeine, Acetaminophen with hydrocodone, Butalbital with Codeine, Codeine, Fentanyl, Hydromorphone, Meperidine, Methadone, Morphine, Oxycodone, Oxymorphone, Propoxyphene Tapentadol, Tramadol
Navy and Marine Corps Public Health Center
Methodology - Extended Medication Use
Drug Classification Drugs Included
Sleep Aids Estazolam, Eszopiclone, Flurazepam, Rozerem, Temazepam, Triazolam, Zaleplon, Zolpidem
SSRI Citalopram (Celexa, Cipram, Cipramil, Citox, Dalsan, Emocal, Recital, Sepram, Seropram), Dapoxetine (Priligy), Desvenlafaxine, Duloxetine, Escitalopram (Cipralex, Esertia, Lexapro), Fluoxetineand not like olanzapin (Depress (UZB), Fluctine (EUR), Fluox(NZ), Fontex, Ladose, Lovan (AUS), Prozac, Sarafem, Seromex, Seronil), Fluvoxamine (Dumyrox, Faverin, Favoxil, Fevarin, Luvox, Movox), Paroxetine (Aropax, Deroxat, Divarius, Loxamine, Paroxat, Paxil, Sereupin, Seroxat, Rexetin, Xetanor), Sertraline(Lustral, Serlain, Zoloft), Vilazodone, Venlafaxine
Stimulants Amphetamine, Atomoxetine, Dextroamphetamine, Methylphenidate
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FHSR Output - Chronic Medication Use
Antidepressants Antipsychotics Anxiolytics Pain
Group Subgroup Deployed Status** Frequency Prevalence*** Frequency Prevalence*** Frequency Prevalence*** Frequency Prevalence***
A
1Not Recently Deployed 73 4.9 18 1.21 34 2.28 150 10.1
Recently Deployed 7 5.86 0 0 2 1.67 12 10
2Not Recently Deployed 32 6.22 4 0.78 9 1.75 61 11.9
Recently Deployed 2 4.07 1 2.03 0 0 9 18.3
3Not Recently Deployed 36 3.25 4 0.36 16 1.45 106 9.58
Recently Deployed 0 0 0 0 2 1.84 9 8.27
4Not Recently Deployed 15 5.16 3 1.03 4 1.38 30 10.3
Recently Deployed 2 6.19 0 0 0 0 3 9.29
TOTAL
Not Recently Deployed 156 4.59 29 0.85 63 1.85 347 10.2
Recently Deployed 11 3.55 1 0.32 4 1.29 33 10.7
GRAND TOTAL 167 4.5 30 0.81 67 1.81 380 10.2
Navy and Marine Corps Public Health Center
FHSR Output - Chronic Medication Use
Sleep Aid SSRI Stimulants
Group Subgroup Deployed Status** Frequency Prevalence*** Frequency Prevalence*** Frequency Prevalence***
A
1Not Recently Deployed 35 2.35 123 8.26 12 0.81
Recently Deployed 4 3.35 8 6.69 1 0.84
2Not Recently Deployed 17 3.3 47 9.14 9 1.75
Recently Deployed 1 2.03 4 8.13 0 0
3Not Recently Deployed 18 1.63 64 5.79 22 1.99
Recently Deployed 2 1.84 3 2.76 2 1.84
4Not Recently Deployed 2 0.69 20 6.88 4 1.38
Recently Deployed 0 0 1 3.1 2 6.19
TOTAL
Not Recently Deployed 79 2.13 270 7.28 52 1.4
Recently Deployed 72 2.12 254 7.47 47 1.38
GRAND TOTAL 7 2.26 16 5.16 5 1.61
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FHSR Output - PDHRA Screening Results
Positive Alcohol Screen^
Positive Depression Screen**
Positive PTSD Screen^^
Positive SuicideHomicide Risk
Screen***
Group SubgroupNumber of Service
Members Screened*Frequency Percent Frequency Percent Frequency Percent Frequency Percent
A
1 150 13 8.67 29 19.3 19 12.7 1 0.67
2 149 4 2.68 17 11.4 12 8.05 2 1.34
3 145 5 3.45 16 11 8 5.52 2 1.38
4 31 1 3.23 10 32.3 7 22.6 0 0
TOTAL 475 23 4.84 72 15.2 46 9.68 5 1.05
Navy and Marine Corps Public Health Center