health on the homefront - wild apricot on...health on the homefront: tina luse, mph, epidemiologist...

6/19/2014

1

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.

Navy and Marine Corps Public Health Center 1

6/19/2014

2

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


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


6/19/2014

3

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


6/19/2014

4

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


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


6/19/2014

5

The Force Health Surveillance Report (FHSR)

Prepared monthly 13-month reporting timeframe Updates information for complete reporting period each month


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


6/19/2014

6

FHSR Structure

Monthly report contains:

– Executive Summary

– Purpose

– Methods

– Results

• Tables and figures

• Individual command structure results

– Discussion

– Limitations

– Appendices


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


6/19/2014

7


DMDC

CTS


(Direct/Theater)

All Behavioral HealthPTSD

Depressive DisorderAlcohol Abuse

TBISuicide Ideation

SIDR


Suicide Ideation

HL7

Outpatient Pharmacy


EDHA




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


6/19/2014

8


DMDC

CTS


(Direct/Theater)


Depressive Disorder

Alcohol AbuseTBI

Suicide Ideation

SIDR


Suicide Ideation

HL7

Outpatient Pharmacy


EDHA




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


6/19/2014

9


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



Condition– Suicide ideation

Case definition– At least ONE outpatient or inpatient visit during report timeframe


Feb 2013 Feb 2014 Mar 2014


6/19/2014

10


DMDC

CTS


(Direct/Theater)


Depressive Disorder

Alcohol AbuseTBI

Suicide Ideation

SIDR


Suicide Ideation

HL7

Outpatient Pharmacy


EDHA




Methodology: Extended Medication Use

Included medication classes

– Antidepressants

– Anxiolytics

– Atypical antipsychotics

– Pain

– Sleep Aids

– Selective Serotonin Reuptake Inhibitors (SSRIs)

– Stimulants


6/19/2014

11


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


November 2013 Feb 2014 Mar 2014



DMDC

CTS


(Direct/Theater)


Depressive Disorder

Alcohol AbuseTBI

Suicide Ideation

SIDR


Suicide Ideation

HL7

Outpatient Pharmacy


EDHA




6/19/2014

12

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


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?


6/19/2014

13

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


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)


6/19/2014

14

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?


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


Recently Deployed 492 0 492




Recently Deployed 323 2 325

TOTAL

Not Recently Deployed 34,011 19 34,030


GRAND TOTAL 37,109 21 37,130


* 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

6/19/2014

15

FHSR Output: Prevalence of Behavioral Health


FHSR Output: Prevalence of Health Conditions


6/19/2014

16

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







TOTAL

Not Recently Deployed 1,136 33.4 268 7.88 304 8.94 214 6.29


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


FHSR Output: Incidence of Extended Drug Use


6/19/2014

17

FHSR Output: PDHRA Screening Results


Discussion

Synthesize results output

– Were observed differences meaningful

– Identify notable changes across the report period

Highlights presented in Executive Summary at start of report


6/19/2014

18

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.


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


6/19/2014

19

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.


Currently Deployed Mar 2014

New Feature - Output


6/19/2014

20

FHSR Annual Report Output




6/19/2014

21





6/19/2014

22





6/19/2014

23

FHSR Next Steps

Include out of network prescriptions Expand examined conditions

– Sleep disorders Analyze long-term trends Improve unit listings


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


6/19/2014

24

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


Supplemental Slides


6/19/2014

25

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


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


6/19/2014

26


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


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


6/19/2014

27

FHSR Output - Chronic Medication Use

Antidepressants Antipsychotics Anxiolytics Pain

Group Subgroup Deployed Status** Frequency Prevalence*** Frequency Prevalence*** Frequency Prevalence*** Frequency Prevalence***

A


Recently Deployed 7 5.86 0 0 2 1.67 12 10


Recently Deployed 2 4.07 1 2.03 0 0 9 18.3


Recently Deployed 0 0 0 0 2 1.84 9 8.27


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


GRAND TOTAL 167 4.5 30 0.81 67 1.81 380 10.2


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


Recently Deployed 1 2.03 4 8.13 0 0




Recently Deployed 0 0 1 3.1 2 6.19

TOTAL

Not Recently Deployed 79 2.13 270 7.28 52 1.4


GRAND TOTAL 7 2.26 16 5.16 5 1.61


6/19/2014

28

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


health on the homefront - wild apricot on...health on the homefront: tina luse, mph, epidemiologist...

Documents