The National Health Study for a New Generation of U.S. Veterans: Surveillance of
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The National Health Study for a New Generation of U.S. Veterans: Surveillance of Post-deployment Health. Aaron I Schneiderman, PhD, MPH, RN Acting Director, Environmental Epidemiology Service Environmental Health Strategic Healthcare Group Office of Public Health August 9, 2011.

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

Aaron I Schneiderman, PhD, MPH, RN

Acting Director, Environmental Epidemiology Service

Environmental Health Strategic Healthcare Group

Office of Public Health

August 9, 2011


Acknowledgments
Acknowledgments Veterans: Surveillance of

Shannon Barth

Steven Coughlin

Stephanie Eber

Erick Ishii

Han Kang

Clare Mahan

Michael Peterson


Objectives
Objectives Veterans: Surveillance of

  • 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 utilization overview
Health Care Utilization Veterans: Surveillance of Overview

  • 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


Updated roster of oef oif ond veterans who have left active duty
Updated Roster of Veterans: Surveillance of OEF, OIF, & OND Veterans Who Have Left Active Duty

  • 1,318,510OEF, 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 2 nd qtr among oef oif ond veterans
VA Health Care Utilization from Veterans: Surveillance of 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/ONDpatients 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 2 nd qtr by service status
VA Health Care Utilization for FY 2002-2011 (2 Veterans: Surveillance of nd 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)

  • 606,421Reserve/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


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.


Frequency of Diagnoses* among Utilizing VA Health Care

OEF, OIF, & OND Veterans

*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.


Oef oif ond veterans diagnosed with a potential traumatic brain injury n 51 331
OEF Utilizing VA Health Care, OIF, & OND VETERANSDIAGNOSED WITH A PotentialTRAUMATIC BRAIN INJURY (N=51,331)

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.


Health care utilization summary
Health Care Utilization Utilizing VA Health CareSummary

  • 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
Previous Utilizing VA Health CareTBI Research

Schneiderman AI, Braver ER, Kang HK

Understanding 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
Methods Utilizing VA Health Care

  • 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 theater

      • Immediate symptoms post-injury

      • Persistent symptoms


Methods ii
Methods II Utilizing VA Health Care

  • 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
Injury Utilizing VA Health Care, 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
Conclusions Utilizing VA Health Care

  • 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
Why a population based epidemiological study? Veterans: Surveillance of Post-deployment Health

  • 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


Methods1
Methods Veterans: Surveillance of Post-deployment Health

  • 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%)


Methods2

Gender Veterans: Surveillance of Post-deployment Health

Male

UnitComponent

Female

Total

Active

9,500

2,400

11,900

Reserve

10,000

8,000

2,000

National Guard

6,500

1,600

8,100

Total

24,000

6,000

30,000

Methods

Sampling distribution of OEF/OIF Veterans and non-OEF/OIF Veterans by gender and unit component


Methods3
Methods Veterans: Surveillance of Post-deployment Health

  • 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%)


Methods4
Methods Veterans: Surveillance of Post-deployment Health

  • 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


Methods5
Methods Veterans: Surveillance of Post-deployment Health

  • Computer Assisted Telephone Interviews (CATI)

    • 2000 participants

    • Additional responses

    • Assess non-response bias

  • Medical records study

    • 1000 participants

    • Consent for non-VA medical records


Questionnaire instruments
Questionnaire Veterans: Surveillance of Post-deployment Health 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 instruments1
Questionnaire Instruments Veterans: Surveillance of Post-deployment Health

  • 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 instruments2
Questionnaire Instruments Veterans: Surveillance of Post-deployment Health

  • 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
Results Veterans: Surveillance of Post-deployment Health

  • 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


Results1
Results Veterans: Surveillance of Post-deployment Health


Results2
Results Veterans: Surveillance of Post-deployment Health


Results3
Results Veterans: Surveillance of Post-deployment Health

32a. During military service did you experience any of the following events?

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


Results4
Results Veterans: Surveillance of Post-deployment Health

32b. Did you have any of the follow IMMEDIATELY after the events in question 32a.?

*Any positive response: Deployed = 31%; Non-deployed = 30%

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


Results5
Results Veterans: Surveillance of Post-deployment Health

33. Did any of the following problems begin or get worse after any of the events in question 32a?

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


Results6
Results Veterans: Surveillance of Post-deployment Health

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

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


Results7
Results Veterans: Surveillance of Post-deployment Health

  • 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


Results8
Results Veterans: Surveillance of Post-deployment Health

  • 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


Results9
Results Veterans: Surveillance of Post-deployment Health

An 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.


Comparison of results among deployed from 2005 survey and 2010 survey
Comparison of results among deployed from 2005 survey and 2010 survey

2005

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

  • 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


Summary
Summary 2010 survey

  • 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


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