formation of a wounded, ill, and injured registry for usn...

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Formation of a Wounded, Ill, and Injured Registry for USN and USMC Service Members

Health on the Homefront:

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

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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.


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

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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



http://www.med.navy.mil/sites/nmcphc/health-promotion/Pages/default.aspxRelax, Relax- available at: http://www.med.navy.mil/sites/nmcphc/health-promotion/psychological-emotional-wellbeing/relax-relax/pages/index.html

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Background


Background


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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.


Mental Health Disorders


Risk factors: young, singer personnel, lower socioeconomic status, enlisted rank, length of service, number of deployments1

9-19% of service members returning from deployment report a behavioral health problem2

10% of total hospitalization included a diagnosis of a behavioral health disorder3

Service members who screen positive for behavioral health disorder are significantly more likely to leave the service early2

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.

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Post-traumatic Stress Disorder (PTSD)


Positive PTSD ranges of 5-13% in soldiers surveyed1

Of those with PTSD, 56% reported using mental health services2

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

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 disorder4

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.

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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.

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 suicide1

2.2% of service members reported they attempted suicide in 2008, compared to just 0.8% in 20052

2,990 service members died by suicide while on active duty from 1998-20113


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.

Injuries

~21% of individuals evacuated from OEF/OIF were due to non-hostile injuries1

In 2009, there were over 27,000 TBIs in the US Military, with over 75% of them classified as mild2

~23% soldiers may have suffered form some form of TBI3,4

From 2001- 2006 there were approximately 8,000 military amputations87.9% due to explosive devices5

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Development

Developed WII methodology working group

– Epidemiologists

– Subject matter experts

– International Classification of Diseases, 9th 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


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.


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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

Methods

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WII Registry only identifies conditions in which encounters occurred after the last recorded deployment

Deployment begin date

Deployment return date*

* If unknown, the average of 210 days was used

Maximum allowed days between deployment return date and date

of first encounter

All encounters for conditions of interest captured

Navy and Marine Corps Public Health Center

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The WII Registry, Example


Active Duty

ID Last NameFirst Name

Date of Birth

ServiceDeployment Location

Depl. Begin date

Depl. End date

UIC FMP PatCat FY of 1st WII Encounter

ICD9, PTSD

ICD9, AUD

ICD9, MDD

ICD9, suicide

ICD9, ampt

ICD9, injury

ICD9, TBI

PTSD AUD MDD Suicide Ampt Injury TBI

Date of most recent encounter

DMIS ID

Active DutyXXX‐XX‐XXXX

Smith John 5/1/1972 Navy Sea 1/1/2012 4/1/2012 234 20 N11 2012 495.2 YES 2013 2356

ReserveXXX‐XX‐XXXX

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


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‐XXXX

Blithers Sara 3/7/1982 Navy Iraq 2/9/2010 6/1/2010 15 20 N13 2011 789.5 YES 2012 2156


Lawser Billy 7/4/1983 Marines Iraq 7/2/2013 8/3/2013 5 20 M11 2013 567.9 YES 2013 8569

Active Duty XXX‐XX‐XXXX

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

Active Duty XXX‐XX‐XXXX

Chatway Larry 10/10/1987 Marines Afghanistan 2/9/2010 6/1/2010 215 20 M11 2010 657.6 YES 2011 8953

Reserve XXX‐XX‐XXXX

Pray Michael 11/15/1985 Navy Sea 2/9/2010 6/1/2010 56 20 N13 2011 456.7 YES 2013 2456

The WII Registry, Example


Active Duty ID Last Name First NameDate of Birth

ServiceDeployment Location


Smith John 5/1/1972 Navy Sea

Deployment Begin Date

Deployment End Date

UIC FMP PatCatFY of 1st WII Encounter

1/1/2012 4/1/2012 234 20 N11 2012

ICD9, PTSD

ICD9, AUD

ICD9, MDD

ICD9, suicide

ICD9, amputations

ICD9, injury

ICD9, TBI

PTSD AUD MDD Suicide Amputations Injury TBI

Date of most recent encounter

DMIS ID

309.81 YES 2013 2356

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Results


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)

Table 1: Average age and days between date of deployment ended to first encounter for WII Registry members, by service

Results


Location of Deployment USMC USNAfghanistan 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

Table 2: Deployment location of WII Registry members, by service

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Results


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.

Table 3: Signature wounds of WII Registry service members, by service

Results


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%

Table 4: Signature wounds of WII Registry service members, by service and component


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Results


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 19.4% 29.4% 18.7% 0.5% 6.4% 23.7% 1.9%

Navy Medicine West 20.2% 29.5% 17.8% 0.8% 5.7% 23.6% 2.5%

Navy Medicine Capital 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%

Table 5: Signature wounds of WII Registry service members, by Navy Medicine Region

† Suicide, suicide ideation, and self-inflicted injuries† † Alcohol use disorder‡ Fractures, dislocations, internal injuries, burns, open wounds, crushing injuries, superficial injuries, poisoning, and contusions.


Figure 1: Virginia Military Treatment Facilities

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Results in Virginia


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%

Table 6: Signature wounds of WII Registry service members in Virginia, by service


Results in Virginia


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%

Table 7: Signature wounds of WII Registry service members in Virginia, by service and component


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Results in Virginia


ServiceFacility

1Facility

2Facility

3Facility

4Facility

5Facility

6Facility

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

Table 8: Cases in Virginia MTFs, by service

Results in Virginia


Table 9: Ranking of conditions, by service

Rank USMC (all) USMC in Virginia USN (all) USN in Virginia

1st TBI MDD MDD MDD

2nd PTSD PTSD AUD AUD† †

3rd MDD TBI PTSD Suicide†

4th AUD† † AUD† † TBI PTSD

5th Suicide† Injuries‡ Suicide† TBI

6th Injuries‡ Suicide† Injuries‡ Injuries‡

7th 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.

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Results


ServiceIndividuals in Case

Management% of Cases

MTFs (all)

USMC 3,542 31.2%

USN 1,922 18.8%

MTFs (Virginia)

USMC 201 40.8%

USN 370 13.9%

Table 10: Case management cases by service

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


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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.


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.


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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.


Contact Information

Dagny [email protected]

757.953.0876

EpiData Center DepartmentNavy and Marine Corps Public Health Center

620 John Paul Jones Circle, Suite 1100Portsmouth, VA 23708

757.953.0700

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