The National Health Study for a New Generation of U.S.

Veterans: Surveillance of Post-deployment Health

Aaron I Schneiderman, PhD, MPH, RNActing Director, Environmental Epidemiology Service Environmental Health Strategic Healthcare GroupOffice of Public Health

August 9, 2011

Acknowledgments

Shannon BarthSteven CoughlinStephanie EberErick IshiiHan KangClare MahanMichael Peterson

Objectives

• Provide VHA health care utilization update• Provide the study background and methods• Present preliminary results for:

– Demographics of study respondents – Responses to the Brief Traumatic Brain Injury

Screening items– PTSD based on the PTSD Checklist -17

Health Care UtilizationOverview

• Environmental Epidemiology Service (EES) receives OEF/OIF/OND roster from DMDC– Cumulative list of SMs who served in Afghanistan

or Iraq since September 2002– Includes Veterans who have left active duty; not

those who are currently serving on active duty– Roster only includes separated OEF/OIF/OND

Veterans with out of theater dates through February 2011

5

Updated Roster of OEF, OIF, & OND Veterans Who Have Left

Active Duty

• 1,318,510 OEF, OIF, & OND Veterans have left active duty and become eligible for VA health care since FY 2002 (out of theater dates through February 2011)

– 712,089 (~54%)* Former Active Duty troops– 606,421 (~46%) Reserve and National Guard

*Percentages reported are approximate due to rounding.

VA Health Care Utilization from FY 2002 through FY2011

(2nd Qtr.) among OEF, OIF, & OND Veterans

• Among all 1,318,510 separated OEF/OIF/OND Veterans

– 683,521 (~52%)* of total separated OEF/OIF/OND Veterans have obtained VA health care since FY

2002 (cumulative total)

• 642,094 of 683,521 (~94%) evaluated OEF/OIF/OND patients have been seen as outpatients only by VA and not hospitalized

• 41,427 of 683,521 (~6%) evaluated OEF/OIF/OND patients have been hospitalized at least once in a VA health care facility

*Percentages reported are approximate due to rounding.

VA Health Care Utilization for FY 2002-2011 (2nd Qtr.) by Service Status

• 712,089 Former Active Duty in DMDC roster– 373,656 (~52%)* have sought VA health care

since FY 2002 (cumulative total)

• 606,421 Reserve/National Guard in DMDC roster**

– 309,865 (~51%)* have sought VA health care since FY 2002 (cumulative total)

*Percentages reported are approximate due to rounding.**May include both former and current Reserve/National Guard Members

8

Demographic Characteristics of OEF, OIF & OND Veterans Utilizing VA

Health Care

* Percentages reported are approximate due to rounding.† A range of birth years is now being reported rather than a range of ages to capture with greater precision the age distribution of OEF/OIF/OND Veterans utilizing VA health care. This began with the 3rd Qtr FY 2009 report.

% OEF/OIF/OND Veterans*

(n = 683,521)

% OEF/OIF/OND Veterans*

(n = 683,521)

Sex Unit TypeMale 88.1 Active Duty 54.7

Female 11.9Reserve/

Guard45.3

Birth Year Cohort† Branch1980 – 1995 45.3 Air Force 12.31970 – 1979 26.3 Army 61.21960 – 1969 21.0 Marines 13.51950 – 1959 6.4 Navy 12.9

1926 – 1949 1.0

RankEnlisted 91.2Officer 8.8

*Includes both provisional and confirmed diagnoses.**These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of March 31, 2011; Veterans can have multiple diagnoses with each health care encounter. A Veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 683,521; percentages add up to greater than 100 for the same reason.† Percentages reported are approximate due to rounding.

Frequency of Diagnoses* among OEF, OIF, & OND Veterans

Diagnosis (Broad ICD-9 Categories)** Frequency Percent†

Infectious and Parasitic Diseases (001-139) 101,158 14.8Malignant Neoplasms (140-209) 8,822 1.3Benign Neoplasms (210-239) 41,121 6.0Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 207,196 30.3Diseases of Blood and Blood Forming Organs (280-289) 23,096 3.4Mental Disorders (290-319) 349,786 51.2Diseases of Nervous System/ Sense Organs (320-389) 294,433 43.1Diseases of Circulatory System (390-459) 139,318 20.4Disease of Respiratory System (460-519) 173,560 25.4Disease of Digestive System (520-579) 242,070 35.4Diseases of Genitourinary System (580-629) 96,624 14.1Diseases of Skin (680-709) 139,159 20.4

Diseases of Musculoskeletal System/Connective System (710-739) 377,205 55.2

Symptoms, Signs and Ill Defined Conditions (780-799) 341,019 49.9

Injury/Poisonings (800-999) 190,188 27.8

OEF, OIF, & OND VETERANSDIAGNOSED WITH A POTENTIAL

TRAUMATIC BRAIN INJURY (N=51,331)ICD-9-CM Diagnosis n=

310.2 Postconcussion Syndrome 11,111800 Fracture of skull 106801 Fracture of base of skull 88802 Fracture of face bones 2,655803 Other and unqualified skull fracture 76804 Multiple fractures involving skull or face with other bones 181850 Concussion 30,755851 Cerebral laceration and contusion 359852 Subarachnoid, subdural, and extradural hemorrhage, following

injury: 216

853 Other and unspecified intracranial hemorrhage following injury

54

854 Intracranial injury of other and unspecified nature 16,800950 Injury to optic nerve and pathways 215

Because there is no ICD-9 code specific to TBI, the above should be considered tentative and provisional. The sum of the number of patients corresponding to each ICD-9 code (n=62,616) is more than 51,331 because a patient may have more than one ICD-9 code.

11

Health Care UtilizationSummary

• Recent OEF, OIF and OND Veterans are presenting to VA with a wide range of medical and psychological conditions.

• The 683,521 OEF, OIF, and OND Veterans who have accessed VA health care were not randomly selected from the population of all Veterans who served and therefore do not constitute a representative sample of all OEF/OIF/OND Veterans.

For example, the fact that 43% of VA patient encounters were coded as being related to diseases of the nervous system/sense organs does not indicate that 43% of all recent Veterans are suffering from this health problem. Only epidemiological studies can evaluate the overall health of OEF/OIF/OND Veterans.

Previous TBI Research

Schneiderman AI, Braver ER, Kang HKUnderstanding sequelae of injury mechanisms

and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: persistent post-concussive symptoms and posttraumatic stress disorder.

Am J Epidemiol 2008;167:1446-1452.

Methods

Study Population– DOD/DMDC roster of National Guard/Reserve or separated active-

duty who served in Afghanistan or Iraq– Residence in Mid-Atlantic

Postal Survey: anonymous Instrument

– Post Traumatic Stress Disorder Checklist-17– Brief Traumatic Brain Injury Screen

History of injury in combat theaterImmediate symptoms post-injuryPersistent symptoms

Methods II• Levels of Mild TBI (mTBI)

– Level 1• Dazed/confused, • Other symptoms: headache, dizziness, irritability

– Level 2 (more severe)• Amnesia for event• Loss of consciousness• Self reported head injury

Injury, mTBI and prevalence of PTSD and post-concussive symptoms in

combat theaters

• 44% reported at least one injury mechanism • 12% had a history of mild TBI in combat theaters

based on immediate symptoms post-injury.• 11% reported symptoms that met conventional

threshold for PTSD• 35% with mTBI reported 3 or more persistent

symptoms that they said were due to head injury (4% of entire population)

Conclusions• Injury

– Common event in combat theaters– mTBI: highly associated with certain mechanisms

• PTSD prevalence– Associated with injury, gender, conflict, mTBI

• Association between mTBI & PTSD– PTSD due to combat exposure? – Is it a symptom of mTBI?

• 3+ current post-concussive symptoms – PTSD strongest association (even after removing sleep &

irritability) – mTBI level 2

• Long term health ramifications/burden of injury?

The National Health Study for a New Generation of U.S. Veterans: Surveillance of Post-deployment

Health

Why a population based epidemiological study?

• Veterans who visit the VAMCs do not tell the entire story

• A survey selecting only deployed doesn’t provide a balanced picture

• Methodology proven using stratified random sampling of the population should provide generalizable data

• Method tests null hypothesis that there is no difference in rates of adverse health effects between deployed and non-deployed

•Population based sample • DoD rosters of deployed• 30,000 OEF/OIF deployed Veterans • 30,000 OEF/OIF era non-deployed Veterans

•Oversampling women (20% versus 11.2%)

Methods

MethodsSampling distribution of OEF/OIF Veterans and

non-OEF/OIF Veterans by gender and unit component

GenderUnit Component Male Female Total

Active 9,500 2,400 11,900

Reserve 8,000 2,000 10,000

National Guard 6,500 1,600 8,100

Total 24,000 6,000 30,000

• Pilot survey– Questionnaires: postal and web-based– Test of cash incentives– n=3000

• Preliminary findings– Mode: web (22.7%) vs. paper (77.3%)– Incentive status

• None (16.7%)• Promised (22.0%)• Prepaid (25.1%)

Methods

• Main survey – Promotion

• PAOs, VSO liaisons, Vet Centers, other internal customers• National VSO leadership• Study website• Social Media: Facebook, Twitter • Toll Free Line

– Modified Dillman method • Invitation letter; Reminder letter

– Web submitted• Three postal survey mailings • Reminder postcards

– Use of monetary incentive

Methods

• Computer Assisted Telephone Interviews (CATI)– 2000 participants– Additional responses– Assess non-response bias

• Medical records study– 1000 participants – Consent for non-VA medical records

Methods

Questionnaire Instruments

• Use of VA health care– Yes or no– Specific services– Satisfaction– If not, why?

• Chronic medical conditions (24 items)– “Has a doctor ever told you…”– DM, HTN, IBS, CFS, CH/AD, Apnea, Asthma, Bronch.

Sinusitis, MS, cirrhosis, hepatitis, stroke• Health care utilization

– Outpatient care, hospitalization, medications, complimentary alternative medicine

Questionnaire Instruments• Standardized measures

– Medical Outcomes Study SF-12– PTSD Checklist (PCL-17)– PHQ9 (TFL note)

• VHA screeners – Traumatic Brain Injury (TBI)

– Adapted from PDHA DD 2796 (BTBIS) – Military Sexual Trauma

• Environmental exposures in the military • 16 items, including:

– Dust/sand, burning trash, fuels, smoke, solvents, insect repellants and pesticides, DU, radiation, industrial pollution, noise, POWs, local food

• Vaccines and malaria prophylaxis

Questionnaire Instruments• Combat exposures

– Wounded?– Danger of being killed?– See anyone wounded, killed or dead?– Discharged weapon in combat?

• Smoking and drinking histories

• Risky driving behaviors

• Reproductive health and pregnancy outcomes

• Contraceptive use (17) before, during, and after military service

• Gynecological outcomes

Results

• Data collection period 8/2009 to 8/2010• Total surveys: n=21,637• Response rate: ~ 36%

– 50% of surveys by Web-based form– 44% by paper survey return– 6% by CATI

• Preliminary results & findings available

ResultsBranch and Component by Deployment Status

to Afghanistan/Iraq n (%)

Deployed Non-Deployed Total Respondents Sample Component

Active Duty 4327 (34.4) 3522 (44.3) 7849 (38.2) 24,000 (40)Nat’l Guard 3735 (29.7) 1866 (23.5) 5601 (27.3) 16,000 (26.7)Reserve 4509 (35.9) 2564 (32.3) 7073 (34.5) 20,000 (33.3)

BranchAir Force 2431 (19.3) 1902 (23.9) 4333 (21.1) 11,648 (19.4)Army 7134 (56.8) 4002 (50.3) 11136 (54.3) 32,754 (54.6)Marines 1236 (9.8) 731 (9.2) 1967 (9.6) 6,794 (11.3)Navy 1770 (14.1) 1317 (16.6) 3087 (15.0) 8,804 (14.7)

Total 12571 (61.2) 7952 (38.8) 20523 (100.0) 60,000 (100)

ResultsSelected Demographic Variables by Deployment Status to

Afghanistan/Iraq n (%)

Deployed Non-Deployed All Respondents Sample

Age24-29 2,823 (22.5) 1,842 (23.1) 4,665 (22.7) 19,841 (33.1)30-39 4,122 (32.8) 2,507 (31.5) 6,629 (32.3) 21,121 (35.2)40-49 3,697(29.4) 1,988 (25.0) 5,685 (27.7) 12,686 (21.1)50-59 1,601 (12.7) 1,269 (16.0) 2,870 (14.0) 5,338 (8.9)60+ 328 (2.6) 346 (4.4) 674 (3.3) 1,014 (1.7)

Marital Status

Married or w/ partner 8,390 (66.7) 5,345 (67.2) 13,735 (66.9) N/AMarried /separated 494 (3.9) 296 (3.7) 790 (3.9) N/ASingle, never married 2,230 (17.7) 1,391 (17.5) 3,621 (17.6) N/A

Divorced 1,382 (11.0) 861 (10.8) 2,243 (10.9) N/AWidowed 38 (0.3) 27 (0.3) 65 (0.3) N/AMissing 37 (0.3) 32 (0.3) 68 (0.3) N/A

Total 12,571 (61.2) 7,952 (38.8) 20,523 (100.0) 60,000 (100)

Results 32a. During military service did you experience any of the

following events?Mechanism* Number (%)

DeployedN=12,596

Non-DeployedN=7,965

a. Blast or Explosion 5,874 (47%) 961 (12%)b. Motor vehicle , aircraft, or water trans. accident 2,940 (23%) 1,397 (18%)c. Fragment or bullet wound above the shoulders 215 (1.7%) 52 (0.7%)

d. Falls 3,963 (32%) 1,968 (25%)

e. Injury from sports/physical training 5,207 (41%) 3,845 (48%)

f. Other 3,236 (26%) 1,909 (24%)

*Any positive response: Deployed = 78%; Non-deployed = 66%

Results 32b. Did you have any of the follow IMMEDIATELY after

the events in question 32a.?

Immediate Symptoms* Number (%)DeployedN=9,780

Non-DeployedN=5,248

Losing consciousness 1,012 (10.4%) 590 (11%)Being dazed, confused, or “seeing stars”** 2,604 (27%) 1,269 (24%)Not remembering the event 735 (7.5%) 343 (6.5%)Concussion 772 (7.9%) 392 (7.5%)Head Injury 848 (8.7%) 447 (8.5%)None 6,566 (67%) 3,592 (69%)

*Any positive response: Deployed = 31%; Non-deployed = 30%**Only reported Being dazed, confused, ”seeing stars”: Deployed = 12%; Non-deployed = 11%

Results 33. Did any of the following problems begin or get worse

after any of the events in question 32a?Sxs begin/worsen after event* Number (%)

DeployedN=3,051

Non-DeployedN=1,565

Memory problems or lapses 1,062 (35%) 342 (22%)Balance problems or dizziness 783 (26%) 366 (24%)Sensitivity to bright light 764 (25%) 272 (17%)Irritability 1,343 (44%) 384 (25%)Headaches 1,358 (45%) 571 (37%)Sleep problems 1,489 (49%) 527 (34%)Trouble concentrating 1,172 (38%) 400 (26%)Hearing problems 1,175 (39%) 289 (18%)No, none of the above 644 (21%) 469 (30%)

*Any positive response: Deployed = 77%; Non-deployed = 68%

Results 33. In the past week, have you had any of the following?

Symptoms in the Past Week* Number (%)DeployedN=2,355

Non-DeployedN= 1,061

Memory problems or lapses 926 (39%) 339 (32%)Balance problems or dizziness 519 (22%) 250 (24%)Sensitivity to bright light 594 (25%) 231 (22%)Irritability 1,310 (56%) 465 (44%)Headaches 1,107 (47%) 493 (47%)Sleep problems 1,491 (63%) 650 (61%)Trouble concentrating 1,114 (47%) 454 (43%)Hearing problems 916 (39%) 288 (27%)No, none of the above 183 (7.8%) 102 (9.6%)

*Any positive response: Deployed = 91%; Non-deployed = 91%

Results

• In the clinical setting endorsement of > one (1) selection on the each of the four screening questions is considered a TBI Screen positive response and generates a consult for a secondary evaluation.

• Under these criteria 17% of the deployed in our survey would generate a consult if they answered the same way to a clinician administered screen.

• This is a preliminary view of the data and should not be interpreted as an estimate of population prevalence of TBI among the deployed

Results

• PTSD Checklist 17 (Weathers et al.)– Measures symptom severity score– Intrusion, Avoidance, Hyper-arousal– Likert scale (1-5, ‘Not at all’ to ‘Extremely’)– Range = 17 to 85– Cut off for (+) screen for symptoms, score = 50

ResultsAn endorsement of PCL-17 scale items with a summed score > 50 is

considered a probable (+) screen for PTSD symptoms in the following table. This is a preliminary view of the data and should not be interpreted as an estimate of population prevalence of PTSD.

PTSD Screening by PTSD Checklist -17 with score cut-off of 50 points as probable screen for symptoms by deployment status and gender (preliminary data)

Deployed (N=12,577) Non-deployed (N=7,942)

PTSD Screen positive

Total

Males

(n=10,098)

Females

(n=2,479) Total

Males

(n=6,077)

Females

(n=1,865)

1,811 (14.4%)

1,496 (14.8%)

315 (12.7%)

736 (9.3%)

536 (8.8%)

200 (10.7%)

Comparison of results among deployed from 2005 survey and 2010 survey

2005• 44% reported at least one

injury mechanism • 12% had a history of mild

TBI in combat theaters based on immediate symptoms post-injury.

• 11% reported symptoms that met conventional threshold for PTSD

2010• 77% reported at least one

injury mechanism • 31% had a history of mild

TBI in combat theaters based on immediate symptoms post-injury.

• 14.4% reported symptoms that met conventional threshold for PTSD

Summary

• Representative response• Data promises information about health status

of OEF/OIF Veterans• Opportunity to analyze self report data on TBI

and PTSD • Potential to conduct further clinical and

epidemiological follow-up studies– Markers for the Identification Norming and

Differentiation of TBI and PTSD (MIND) Study