The Accession Medical Standards Analysis Research Activity AMSARA

1. 1

2. 2 Background Medical Accession Process Review of Attrition Past Studies (including back-up slides) Current Studies Assessment of Recruit Motivation and Strength (ARMS) Psychiatric Screening of Military Applicants Agenda

3. 3 1997 Government Accounting Office Report on Military Attrition Accession Medical Standards Steering Committee Accession Medical Standards Working Group Charter Joint Vision 2010 Document (Chairman of the Joint Chiefs of Staff) Background & Justification

4. 4 Established in 1996 in the Division of Preventive Medicine, Walter Reed Army Institute of Research (WRAIR) Supports the DoD Accession Medical Standards Working Group (AMSWG) and the USD Personnel and Readiness MEDPERS Committee

5. 5 We see our mission as supporting the development of evidence-based accession standards through one, guiding necessary improvements in the medical and administrative databases underlying standards evaluation; two, conducting epidemiologic analyses to provide military-specific insights into accession issues; and three preparing policy recommendation that integrate relevant operational, clinical and economic considerations We see our mission as supporting the development of evidence-based accession standards through one, guiding necessary improvements in the medical and administrative databases underlying standards evaluation; two, conducting epidemiologic analyses to provide military-specific insights into accession issues; and three preparing policy recommendation that integrate relevant operational, clinical and economic considerations

6. 6 AMSARA Objectives: Validate current and proposed standards Validate assessment techniques Medical and administrative quality assurance Optimize assessment techniques Track impact of policies, procedures, and waivers Recommend changes to enhance readiness, protect health, and save money AMSARA has six specific objectives. Objective 1 is to validate current and proposed standards. Though the issues studied are ideally prioritized based on a perspective developed from the data rather than from what is politically �hot� at the moment, it is likely that these issues will be prominent items on the agenda for the next year or two. The AMSARA will approach many of these questions using �survival analysis� methods. An example of a hypothetical survival analysis is shown on the right. In it persons with flat foot waivers are compared with those who don�t need a waiver. At accession 100% are �survivors�, that is on active duty and unscathed. As time passes, a certain number of both groups fail to �survive�. A failure to survive can be represented by endpoints such as an EPTS discharge, a foot-related hospitalization, or another non-favorable outcome. Completed five year survival analysis this year address the accession standards for asthma, attention deficit disorder and psychiatric disorders (�neurosis�). AMSARA has six specific objectives. Objective 1 is to validate current and proposed standards. Though the issues studied are ideally prioritized based on a perspective developed from the data rather than from what is politically �hot� at the moment, it is likely that these issues will be prominent items on the agenda for the next year or two. The AMSARA will approach many of these questions using �survival analysis� methods. An example of a hypothetical survival analysis is shown on the right. In it persons with flat foot waivers are compared with those who don�t need a waiver. At accession 100% are �survivors�, that is on active duty and unscathed. As time passes, a certain number of both groups fail to �survive�. A failure to survive can be represented by endpoints such as an EPTS discharge, a foot-related hospitalization, or another non-favorable outcome. Completed five year survival analysis this year address the accession standards for asthma, attention deficit disorder and psychiatric disorders (�neurosis�).

7. 7

8. 8 The accession medical standards are detailed in DoD Directive 6130. There intent is to identify pre-existing conditions in the recruit population that would prevent successful completion of basic training and military service. These standards apply to all military services and both officers and enlisted. AMSARA uses epidemiologic data to validate the current standards and make recommendations to change standards as indicated by analysis. Data analyzed includes: accession disqualifications, medical waivers, medical (EPTS and medical boards) and administrative separations, hospitalizations, and ambulatory clinic visits. The goal is to use epidemiologic data to develop evidence based accession standards that maximize successful accession into military service and minimize all cause attrition.The accession medical standards are detailed in DoD Directive 6130. There intent is to identify pre-existing conditions in the recruit population that would prevent successful completion of basic training and military service. These standards apply to all military services and both officers and enlisted. AMSARA uses epidemiologic data to validate the current standards and make recommendations to change standards as indicated by analysis. Data analyzed includes: accession disqualifications, medical waivers, medical (EPTS and medical boards) and administrative separations, hospitalizations, and ambulatory clinic visits. The goal is to use epidemiologic data to develop evidence based accession standards that maximize successful accession into military service and minimize all cause attrition.

9. 9 Before discussing some completed studies, I would like to provide a brief overview of enlisted accession and attrition to illustrate why we need this sort of surveillance project. The primary applicant pool for military accessions are persons 18 to 24 years old. In the US there are approximately 25 million persons in this group. For every birth year group, recruiters need to successfully enlist about 11% of the men and about 1% of the women. More actually need to be recruited because some are disqualified either by the recruiter or as a result of the Military Entrance Processing Command evaluations. In the five year period from FY 95 to 99 the MEPCOM performed an annual average of 225,000 exams to approximately 138,000 accessions. Twelve percent of the applicants were disqualified permanently by MEPCOM and 6,800 (5.0%) of the accessions came in with waivers. After recruitment, the recruit stays in the delayed entry program for a variable period of time before returning to the MEPS station for shipment to the basic training center. Before discussing some completed studies, I would like to provide a brief overview of enlisted accession and attrition to illustrate why we need this sort of surveillance project. The primary applicant pool for military accessions are persons 18 to 24 years old. In the US there are approximately 25 million persons in this group. For every birth year group, recruiters need to successfully enlist about 11% of the men and about 1% of the women. More actually need to be recruited because some are disqualified either by the recruiter or as a result of the Military Entrance Processing Command evaluations. In the five year period from FY 95 to 99 the MEPCOM performed an annual average of 225,000 exams to approximately 138,000 accessions. Twelve percent of the applicants were disqualified permanently by MEPCOM and 6,800 (5.0%) of the accessions came in with waivers. After recruitment, the recruit stays in the delayed entry program for a variable period of time before returning to the MEPS station for shipment to the basic training center.

10. 10 This slide illustrates the stages of an enlisted first tour of duty, and types of attrition. Applicants are medically evaluated at the Military Entrance Processing Stations or MEPS, and either qualified or disqualified. Qualified recruits and disqualified recruits with an approved waiver then go to Initial Entry Training (IET) where they complete basic training, followed by advanced individual training. Overall attrition from basic and advanced individual training is estimated at 15%. From IET, they proceed to their first duty location. At any time during their enlistment, they can receive medical care, be discharged for a medical reason, or be discharged for a non-medical reason. Medical conditions that present during the first 180 days of service can result in an Existed Prior to Service Discharge (EPTS). One third of all IET separations are due to EPTS discharges (4.4% of all Army trainees). All cause attrition for the Army within two years of service from accession is approximately 20%. Upon completion of their first term, they can leave the service or continue on active duty, from which they can also be discharged for various reasons. This slide illustrates the stages of an enlisted first tour of duty, and types of attrition. Applicants are medically evaluated at the Military Entrance Processing Stations or MEPS, and either qualified or disqualified. Qualified recruits and disqualified recruits with an approved waiver then go to Initial Entry Training (IET) where they complete basic training, followed by advanced individual training. Overall attrition from basic and advanced individual training is estimated at 15%. From IET, they proceed to their first duty location. At any time during their enlistment, they can receive medical care, be discharged for a medical reason, or be discharged for a non-medical reason. Medical conditions that present during the first 180 days of service can result in an Existed Prior to Service Discharge (EPTS). One third of all IET separations are due to EPTS discharges (4.4% of all Army trainees). All cause attrition for the Army within two years of service from accession is approximately 20%. Upon completion of their first term, they can leave the service or continue on active duty, from which they can also be discharged for various reasons.

11. 11 AMSARA Makes Sense:Salient points Over 240,000 accession medical exams per year and approximately 140,000 accessions per year Recruiting, screening, and training costs run approximately $35,000 per enlistee (FY03) About 14% (>18,000/yr) of recruits fail to finish IET About 5% leave with EPTS conditions About 33% of enlistees fail to finish first tour To summarize this issue, MEPS applies current accession standards to over 300,000 exams per year. For those who ultimately take the oath and enter, DoD spends about $30,000 per enlistee. Regrettably more than 25,000 enlistees per year wash out during initial training with about a third overall failing to finish their first tour. Considering the costs represented by these losses, AMSARA is a miniscule investment. The bottom line is that every time AMSARA identifies the means to prevent 20 attritions, it pays for itself and this does not include any savings from avoided medical care, sick leave, or disability.To summarize this issue, MEPS applies current accession standards to over 300,000 exams per year. For those who ultimately take the oath and enter, DoD spends about $30,000 per enlistee. Regrettably more than 25,000 enlistees per year wash out during initial training with about a third overall failing to finish their first tour. Considering the costs represented by these losses, AMSARA is a miniscule investment. The bottom line is that every time AMSARA identifies the means to prevent 20 attritions, it pays for itself and this does not include any savings from avoided medical care, sick leave, or disability.

12. 12 We used 1997 to 2002 to have adequate follow up to compare accession and attrition across various DQ categories. Another reason to exclude 2003 and 2004 was that due to OEF and OIF, the applicants and accessions have decreased significantly in 2003 & 2004We used 1997 to 2002 to have adequate follow up to compare accession and attrition across various DQ categories. Another reason to exclude 2003 and 2004 was that due to OEF and OIF, the applicants and accessions have decreased significantly in 2003 & 2004

14. 14 Current Screening Process Challenges Disqualifies many who can serve successfully Amongst AD accessions < 5% have a waiver Waiver studies show few of those waived receive an EPTS discharge for the waived condition Fails to identify many with disqualifying conditions Approximately 5% of all accessions are EPTS discharged EPTS studies show few were disqualified and waived for that condition

15. 15 Types of Studies Conducted Descriptive, Case Series, Case-control Characterize applicants, accessions, hospitalizations, EPTS, disability discharges Waived for pre-existing conditions Asthma, ADHD, Back, Knee, Skin, Mental Health Program assessment Chlamydia screening, Injury rehab, Coping skills Retrospective study of discharges Asthma, Psychiatric, Fort Jackson EPTS General attrition modeling To include Survival analysis, multivariate analysis, Logistic Modeling, Multiple Event Modeling Prospective efficacy trials challenging accession standards and screening The types of studies AMSARA conducts are listed on this slide. Descriptive statistics considered include: age, gender, race, education, AFQT, presence of disqualifying conditions, and receipt of medical waivers, hospitalizations, EPTS, and disability discharge within first year of service. Studies conducted and ongoing include: survival analysis, program assessment, intervention trials, and cost effective analysis, and multivariate attrition modeling. Retrospective and prospective study designs have been employed.The types of studies AMSARA conducts are listed on this slide. Descriptive statistics considered include: age, gender, race, education, AFQT, presence of disqualifying conditions, and receipt of medical waivers, hospitalizations, EPTS, and disability discharge within first year of service. Studies conducted and ongoing include: survival analysis, program assessment, intervention trials, and cost effective analysis, and multivariate attrition modeling. Retrospective and prospective study designs have been employed.

16. 16 AMSARA accesses a variety of existing databases. There is considerable effort given to work with the managers of these databases to improve the data being collected. One unique aspect of our data is the coding of EPTS discharges which we receive from MEPCOM. AMSARA reviews each EPTS record and assigns ICD-9 diagnoses for all conditions listed allowing for disease specific studies to be done. DODMERB is instituting an automated database to track officer accessions for all three services. This should allow AMSARA do officer accession analysis comparable to enlisted. PASBA provides AMSARA with ADS data pertaining to clinic visits and hospitalizations which are outcomes of interest in our survival analysis studies. Disability data is received for Army and Air Force and is also used as a source of attrition within the first year of service for accessions. The Army OTSG is currently seeking understanding of a five year trend of increasing disability discharge rates in the face of decreasing force strength. AMSARA is uniquely poised to address this question with available data sources and analytical capabilities.AMSARA accesses a variety of existing databases. There is considerable effort given to work with the managers of these databases to improve the data being collected. One unique aspect of our data is the coding of EPTS discharges which we receive from MEPCOM. AMSARA reviews each EPTS record and assigns ICD-9 diagnoses for all conditions listed allowing for disease specific studies to be done. DODMERB is instituting an automated database to track officer accessions for all three services. This should allow AMSARA do officer accession analysis comparable to enlisted. PASBA provides AMSARA with ADS data pertaining to clinic visits and hospitalizations which are outcomes of interest in our survival analysis studies. Disability data is received for Army and Air Force and is also used as a source of attrition within the first year of service for accessions. The Army OTSG is currently seeking understanding of a five year trend of increasing disability discharge rates in the face of decreasing force strength. AMSARA is uniquely poised to address this question with available data sources and analytical capabilities.

17. 17 Numerous collaborative studies are in progress throughout WRAIR and with other services, as well as industry, university researchers, and CHPPM.Numerous collaborative studies are in progress throughout WRAIR and with other services, as well as industry, university researchers, and CHPPM.

18. 18 ARMS: Physical Performance Testing Step- test (modified Harvard step test) Step is 16� men and 12� women Perform step-test for 5 minutes, 30 steps per minute Heart rate 1 minute post-exercise All difficulties performing the test will be noted Motivation is a factor in performing this test Difficult to perform for those with lower extremity problems Push-ups Number done in one minute 15 for men and 4 for women Incremental Dynamic Lift (Military Press) Maximal weight lifted, 50 lbs men and 40 lbs women Utilized by the Air Force

19. 19 Methodology Cohort study conducted at 6 MEPS San Diego, Chicago, Sacramento, San Antonio, Buffalo & Atlanta Three phase study WRAIR Institutional Review Board Approved Phase I & II Completed Feb 2005 Funding: US Army Accession Command ($450K) & MEPCOM ($300K) Physical performance testing required but not will not impact qualification status Determine ability of ARMS test to predict future attrition and morbidity in general recruit population Phase III Automatic waiver for over body fat applicants who pass ARMS Up to a maximum body fat of 30% for males and 36% for females Funding: US Army Accession Command ($300K) & ARNG ($400K) Enrollment from Feb 05 thru Dec 2006 with one year follow-up for morbidity and attrition Phase IV Pending DA UFR funding Automatic waiver for selected (to be determined) musculoskeletal conditions who pass ARMS in CY 2006

20. 20 Study Size & Expected Outcomes Need ~4,000 phase III who meet Wt or BF applicants and ~1,100 phase III over body fat Assuming 75% to pass the ARMS test Assuming ~70% to ship to BCT Assuming ~90% to remain on active duty for at least 60 days 87% probability (power) of detecting at least 50% fewer discharges in the ARMS qualified group as compared to those who failed it 95% probability of detecting a 30% difference in attrition between those over body fat and those within standards

21. 21 ARMS Phase III 60-Day Attrition Results*as of 12 July 2005 This slide depicts 60-day attrition in Phase III participants as of 12 July. Applicants shipped NLT 12 May 05 to allow all recruits to have at least 60 days at IET. There was no significant difference between the over-body fat applicants (male and female) and the fully qualified applicants (male and female). This slide depicts 60-day attrition in Phase III participants as of 12 July. Applicants shipped NLT 12 May 05 to allow all recruits to have at least 60 days at IET. There was no significant difference between the over-body fat applicants (male and female) and the fully qualified applicants (male and female).

22. 22 Relative Risk of 60 Day Attrition in ARMS Waived Over Body Fat versus Met Body Fat Standard RELATIVE RISK OF ATTRITION AMONG OVERWEIGHT/OVER BODY FAT SHIPPERS VERSUS THOSE NOT OVER BODY FAT: ARMS PHASE III SUBJECTS 8 FEB-12 MAY 05 Losses/Group Days follow-up ARMS waiver Not Over Fat Est. RR LCL UCL Females 60 53 173 1.72 0.85 3.46 Males 60 134 1045 1.07 0.57 2.02 Total 60 187 1218 1.42 0.90 2.24 RELATIVE RISK OF ATTRITION AMONG OVERWEIGHT/OVER BODY FAT SHIPPERS VERSUS THOSE NOT OVER BODY FAT: ARMS PHASE III SUBJECTS 8 FEB-12 MAY 05 Losses/Group Days follow-up ARMS waiver Not Over Fat Est. RR LCL UCL Females 60 53 173 1.72 0.85 3.46 Males 60 134 1045 1.07 0.57 2.02 Total 60 187 1218 1.42 0.90 2.24

23. 23 Discussion Early results show no significant increased risk of attrition in those who are over body fat and pass the ARMS test compared to those within weight or BF standard Insufficient study population and incomplete longitudinal review of attrition precludes formulation of definitive conclusions and recommendations Based on these early results, there appears to be no increased risk of attrition in those who are over body fat and pass the ARMS test compared to those within weight or BF standard. At this time, however, the insufficient study population and incomplete longitudinal review of attrition precludes formulation of definitive conclusions and recommendations. Based on these early results, there appears to be no increased risk of attrition in those who are over body fat and pass the ARMS test compared to those within weight or BF standard. At this time, however, the insufficient study population and incomplete longitudinal review of attrition precludes formulation of definitive conclusions and recommendations.

24. 24 This slide shows the cumulative number of injuries in male study participants (WT/BF qualified versus OBF) from 8 Feb 05 to 22 Aug 05 by injury type. It therefore includes variable lengths of follow-up or person-time at risk for injury.This slide shows the cumulative number of injuries in male study participants (WT/BF qualified versus OBF) from 8 Feb 05 to 22 Aug 05 by injury type. It therefore includes variable lengths of follow-up or person-time at risk for injury.

25. 25 This slide shows the cumulative number of injuries in female study participants (WT/BF qualified versus OBF) from 8 Feb 05 to 22 Aug 05 by injury type. It therefore includes variable lengths of follow-up or person-time at risk for injury. This slide shows the cumulative number of injuries in female study participants (WT/BF qualified versus OBF) from 8 Feb 05 to 22 Aug 05 by injury type. It therefore includes variable lengths of follow-up or person-time at risk for injury.

26. 26 Relative Risk of 60 Day First Injury All Cause in ARMS Waived Over Body Fat versus Met Body Fat Standard thru Aug 05 This slide reports the relative risk of all cause, first injury only in those with at least 60 days of active duty serviceThis slide reports the relative risk of all cause, first injury only in those with at least 60 days of active duty service

27. 27 The demographic distributions between those over body fat and those met body fat standard are different We selected controls from those met body fat with 3:1 by matching gender, race, age and ship time of those over body fat to control the confounding effect of those factors follow up until 08/25/05 The following charts show the probability to be injury free by Kaplan Meier Survival Analysis Three tests were used: log-rank, Wilcoxon and Likelihood ratio. Matching criteria for other known predictors of attrition for males include Race (white and other) and age (21 and younger, 22 and above) and shipment month There are 235 OBF male individuals in phase The demographic distributions between those over body fat and those met body fat standard are different We selected controls from those met body fat with 3:1 by matching gender, race, age and ship time of those over body fat to control the confounding effect of those factors follow up until 08/25/05 The following charts show the probability to be injury free by Kaplan Meier Survival Analysis Three tests were used: log-rank, Wilcoxon and Likelihood ratio. Matching criteria for other known predictors of attrition for males include Race (white and other) and age (21 and younger, 22 and above) and shipment month There are 235 OBF male individuals in phase

28. 28 Matching criteria for other known predictors of attrition for Females include Race (white and other) and age (21 and younger, 22 and above) There are 70 female OBF individuals in phase 3 Matching criteria for other known predictors of attrition for Females include Race (white and other) and age (21 and younger, 22 and above) There are 70 female OBF individuals in phase 3

29. 29 Injury Data Analysis Increased overall risk of all cause injury for both males and females who exceed body fat standards compared to fully qualified Leading injury categories are minor and include sprains and pain in joints Heat injuries and fractures are uncommon in both fully qualified and over body fat Current small numbers preclude definitive comparisons for individual injury categories Recommend ongoing testing and data collection

30. 30 Potential Benefits of Adding a Performance Test Emphasis on physical fitness prior to entry Recruiters provide information to applicants on how to train Increase potential recruiting pool by at least 33 million > 11,000 more annual accessions to BCT A measure of applicant motivation Losses will be moved �far to the left� based on measurable criteria likely to be related to future attrition Decreased injuries during BCT with higher level of physical fitness prior to entry

31. 31 Psychiatric Disorders: Burden of Disease Medical failures (permanent disqualifications): 4.6% of all medical failures with over 2,300 per year from 1995 to 2000 � Medical Waivers: 5.5% of all AD waivers from 1995 to 2000 Top 5 Causes: attention deficit, depression, suicide, drug abuse, enuresis EPTS discharges: 27.2% of all AD EPTS discharges from 1996 to 2001 with over 2,200 per year Top 5 Causes: Depression, Behavior, Personality, Suicide, attention deficit

32. 32 Research Objectives To develop a rapid, inexpensive method to screen military recruits for major psychiatric disorders or other behavioral factors that strongly predict occupational dysfunction in the military Results should be standardized and interpretable by physicians without specialty training in psychiatry The screening test should be reliable, and valid without significant health risk to persons tested

33. 33 Small Business Initiative Research (SBIR) OSD has awarded two contracts to develop a psychiatric screen for use at the MEPS Phase I (completed in 2002) Lasted for 6 months at a cost of $100,000 per contract Resulted in the development of two questionnaire prototypes Focused on depression, anxiety, psychiatric medication, alcohol, personality, adverse childhood events, psychoticism, function, motivation, self-esteem, social desirability, and executive function

34. 34 SBIR: Phase II Two year (2003 to 2005) contract awarded to both contractors for $750,000 each Both contractors have conditional Human Subjects Research Review Board approval Pending US MEPCOM approval to begin validation studies in selected MEPS (a total of 8 sites) Informed consent will be obtained by research assistant A cash incentive for participation will be offered The two electronic questionnaires are 187 and 317 items and are designed to be completed in 40 and 90 minutes respectively Projected study sample size is over 5,000 participants for each contract

35. 35 SBIR: Phase II Questionnaires include items to detect malingering and �faking good� Study participants will be followed for at least 6 months on active duty for psychiatric disorders as well medical and administrative discharges Objective is to develop a predictive model for psychiatric disorders in military applicants Goal is to reduce attrition in Initial Entry Training attrition due to psychiatric disorders by at least 10%

36. Questions?

37. 37 I would like to mention here that the program has just completed its fourth year in operation. With one of its first analysis and policy recommendations, elimination of syphilis screening, AMSARA has already saved more in one year that it takes to operate the program for five years. To the credit of MAJ Clark who ran the program until June 99 when she left the Army, there have been three publications on AMSARA�s work, the latest in the American Journal of Preventive Medicine (provide copy). I will mention the second bullet here which began our work with asthma. This three year study confirmed that attrition is not unusually high among those waived for asthma. Unfortunately 70% of those discharged with asthma did not reveal their condition to you during the MEPS exam. This prompted us to do additional studies on asthma which I will discuss later. Another study compared cases waived for orthopedic knee conditions (ligamentous or meniscal conditions) to matched controls. Those in the Army were more likely to be discharged early, however the relative numbers were small so it is unlikely to be cost-effective to change the current mass screening or waiver process for military recruits with these conditions. Preliminary ADHD study presented in the 1997 study was extended in 1998 to three year follow-up and in 2000 to five years. Thus far, those waived for a hx/o ADHD had similar discharge rates when compared with matched controls. Preliminary results examining flat feet EPTS discharges failed to show any correlation with disqualification rates for foot problems at MEPS All of these projects have significant accession policy implications and potential cost savings to DOD. I would like to mention here that the program has just completed its fourth year in operation. With one of its first analysis and policy recommendations, elimination of syphilis screening, AMSARA has already saved more in one year that it takes to operate the program for five years. To the credit of MAJ Clark who ran the program until June 99 when she left the Army, there have been three publications on AMSARA�s work, the latest in the American Journal of Preventive Medicine (provide copy). I will mention the second bullet here which began our work with asthma. This three year study confirmed that attrition is not unusually high among those waived for asthma. Unfortunately 70% of those discharged with asthma did not reveal their condition to you during the MEPS exam. This prompted us to do additional studies on asthma which I will discuss later. Another study compared cases waived for orthopedic knee conditions (ligamentous or meniscal conditions) to matched controls. Those in the Army were more likely to be discharged early, however the relative numbers were small so it is unlikely to be cost-effective to change the current mass screening or waiver process for military recruits with these conditions. Preliminary ADHD study presented in the 1997 study was extended in 1998 to three year follow-up and in 2000 to five years. Thus far, those waived for a hx/o ADHD had similar discharge rates when compared with matched controls. Preliminary results examining flat feet EPTS discharges failed to show any correlation with disqualification rates for foot problems at MEPS All of these projects have significant accession policy implications and potential cost savings to DOD.

38. 38 Five year survival study of those entering active duty having received a waiver for a prior diagnosis of ADHD remain on active duty as long as the general recruit population Five year survival study of those entering active duty having received a waiver for a prior diagnosis of asthma were more likely to remain on active duty than the general recruit population Five year survival study of those waived for mental health disorders are at increased risk for both psychiatric hospitalization and attrition than the general recruit population

39. 39 EPTS case series reviews in support of the AMSWG review of DoDI 6130: hernia, hepatitis, TMD, thyroid, diabetes mellitus, abnormal pap smears, varicocele, & enuresis Early hospitalization for injury and subsequent attrition Interim reports on the retention of Mild Asthmatics in the Navy (REMAIN) & Asthma EPTS studies 6 month of Military Service Psychiatric Hospitalization and Subsequent Risk of Attrition

40. 40 EPTS case series reviews in support of the AMSWG review of DoDI 6130: hearing loss scoliosis low back pain Survival analysis of recruits with a waiver for pes planus showed increase risk of attrition while scoliosis, headache, and hypertension showed no difference in attrition Interim report on the Review of Initial Entry Training Discharges at FT Leonard Wood

41. 41 EPTS case series reviews in support of the AMSWG review of DoDI 6130: depression, pes planus, hypertension, headache, & retropatellar pain syndrome Completed data collection in the use of exhaled nitric oxide as a predictor of asthma in MEPS applicants (n=2800+) Completed data collection in the asthma EPTS study at FT Jackson & FT Knox (n=4000+) Completed data collection in the Review of Initial Entry Training Discharges at FT Leonard Wood (n=2900+)

42. 42 Myopia waiver survival analysis showed no difference in attrition EPTS case series review of myopia in support of the AMSWG review of DoDI 6130.4 Completed a BUMED waiver application review of approved and denied cases of asthma, ADHD and hearing loss Completed analysis of the Review of Initial Entry Training Discharges at FT Leonard Wood (n=2900+) Studied the trend in military applicants from 2000 to 2004 Studied the trend in military hospitalizations from 1999 to 2003

43. 43 Early Attrition Among Military Enlistees: Finding Significant Prediction Factors (1999 AMSARA Annual Report) Identification and quantification of risk factors for early enlisted attrition Risk factors selected from information known to services at time of application Service-specific analyses Each factor adjusted for effects of the others The 1999 AMSARA Annual Report contains a study of early military attrition among new active duty enlistees. The study looks at the effects of several demographic, medical, and other factors which are known at the time of application for service, on the likelihood of subsequent attrition among enlistees. Cox proportional hazards modeling was used to perform these analyses. The relative strength of several predictors are examined, including the service branch being joined, presence of a medically disqualifying condition, academic aptitude and achievement, and demographic factors such as age, race and gender. The 1999 AMSARA Annual Report contains a study of early military attrition among new active duty enlistees. The study looks at the effects of several demographic, medical, and other factors which are known at the time of application for service, on the likelihood of subsequent attrition among enlistees. Cox proportional hazards modeling was used to perform these analyses. The relative strength of several predictors are examined, including the service branch being joined, presence of a medically disqualifying condition, academic aptitude and achievement, and demographic factors such as age, race and gender.

44. 44 Extension of attrition modeling to consider changing effects of attrition predictors over service time (2003 AMSARA Annual Report) Effects of attrition predictors found to vary over service time Time-dependent model introduced to develop more accurate picture Factors found to affect only earliest attrition may be handled differently from those with long-term effect AMSARA is now working to extend the 1999 attrition study to include attrition follow-up through the first three years of duty. With this additional follow-up time, the first step was to assess whether the Cox proportional hazards model is still the appropriate model. In particular, we wanted to see if the effects of the predictive factors on attrition remain fairly constant over the longer follow-up period. Indeed, we found that this was not the case for several of the factors. Therefore, we have employed time-dependent models which allow for detailed interpretation of the effects of predictive factors on attrition over the first few years of service. AMSARA is now working to extend the 1999 attrition study to include attrition follow-up through the first three years of duty. With this additional follow-up time, the first step was to assess whether the Cox proportional hazards model is still the appropriate model. In particular, we wanted to see if the effects of the predictive factors on attrition remain fairly constant over the longer follow-up period. Indeed, we found that this was not the case for several of the factors. Therefore, we have employed time-dependent models which allow for detailed interpretation of the effects of predictive factors on attrition over the first few years of service.

45. This graph shows the results of modeling attrition at different times of service, and the effects on attrition of several factors over time. For example, we find that the presence of a medically disqualifying condition (with subsequent medical waiver) is associated with a 25-30% increase in attrition risk during the first 3 months of service. However, this risk drops dramatically after that initial period of high risk, meaning that the risk associated with an initial medical disqualification is mostly an early phenomenon. It is important to keep in mind that we are not addressing �causality� in this study, so the attrition you see is not necessarily a direct or even indirect result of a medical condition. This graph shows the results of modeling attrition at different times of service, and the effects on attrition of several factors over time. For example, we find that the presence of a medically disqualifying condition (with subsequent medical waiver) is associated with a 25-30% increase in attrition risk during the first 3 months of service. However, this risk drops dramatically after that initial period of high risk, meaning that the risk associated with an initial medical disqualification is mostly an early phenomenon. It is important to keep in mind that we are not addressing �causality� in this study, so the attrition you see is not necessarily a direct or even indirect result of a medical condition.

46. 46 AMSARA Detailed Examinations of Medical Waiver Approvals All waiver approval records for a given condition (e.g. asthma) selected Those with secondary conditions excluded Only approved waivers with an accession (gain) record included Matched comparison subjects with no waiver needed selected (matched on age, sex, race, service, time of beginning duty, etc.) Subject groups tracked and compared for overall attrition, medical attrition, hospitalization, clinic visits, disability, other

47. 47 Waiver Survival Studies of Various Medically Disqualifying Conditions Comparing Waived and Matched Fully Qualified Comparison Active Duty Enlisted Accessions

48. Log Rank test p<0.05Log Rank test p<0.05

49. Log Rank test p>0.05Log Rank test p>0.05

50. Log Rank test p<0.05Log Rank test p<0.05

51. 51 Hospitalization rates among enlistees with a waiver for pes planus versus matched comparison subjects