Update on Traumatic Brain Injury Surveillance and Research ...

Update on Traumatic Brain Injury Surveillance and Research ...

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 Shannon Barth Steven Coughlin Stephanie Eber Erick Ishii Han Kang Clare Mahan Michael 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 Utilization 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 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. 5 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 373,656 606,421 (~52%)* have sought VA health care since FY 2002 (cumulative total) 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 Demographic Characteristics of OEF, OIF & OND Veterans Utilizing VA Health Care % OEF/OIF/OND Veterans* (n = 683,521) Sex % OEF/OIF/OND Veterans* (n = 683,521) Unit Type Male Female 88.1 11.9 Birth Year Cohort 1980 1995

1970 1979 1960 1969 1950 1959 1926 1949 Active Duty Reserve/Guard 54.7 45.3 Branch 45.3 26.3 21.0 6.4 1.0 Air Force Army Marines Navy 12.3 61.2 13.5 12.9

Rank Enlisted Officer 91.2 8.8 * 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. 8 Frequency of Diagnoses* among OEF, OIF, & OND Veterans Diagnosis (Broad ICD-9 Categories)** Frequency Percent 101,158 14.8

8,822 1.3 41,121 6.0 207,196 30.3 23,096 3.4 Mental Disorders (290-319) 349,786 51.2 Diseases of Nervous System/ Sense Organs (320-389) 294,433 43.1

Diseases of Circulatory System (390-459) 139,318 20.4 Disease of Respiratory System (460-519) 173,560 25.4 Disease of Digestive System (520-579) 242,070 35.4 96,624 14.1 Diseases 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 Infectious and Parasitic Diseases (001-139) Malignant Neoplasms (140-209) Benign Neoplasms (210-239) Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) Diseases of Blood and Blood Forming Organs (280-289) Diseases of Genitourinary System (580-629)

*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) ICD-9-CM 310.2 800 801 802 803 804 850 851 852 853 854 950 Diagnosis Postconcussion Syndrome

Fracture of skull Fracture of base of skull Fracture of face bones Other and unqualified skull fracture Multiple fractures involving skull or face with other bones Concussion Cerebral laceration and contusion Subarachnoid, subdural, and extradural hemorrhage, following injury: Other and unspecified intracranial hemorrhage following injury Intracranial injury of other and unspecified nature Injury to optic nerve and pathways n= 11,111 106 88 2,655 76 181 30,755 359 216 54 16,800 215

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. Health Care Utilization Summary 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. 11 Previous TBI 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 Study Population DOD/DMDC roster of National Guard/Reserve or separated activeduty 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 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 doesnt 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

Methods 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 Sampling distribution of OEF/OIF Veterans and non-OEF/OIF Veterans by gender and unit component Unit Component Gender Male Female Active 9,500 2,400 11,900

Reserve 8,000 2,000 10,000 National Guard 6,500 1,600 8,100 24,000 6,000 30,000 Total Total

Methods 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 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 Results Branch and Component by Deployment Status to Afghanistan/Iraq n (%) Deployed Non-Deployed Total Respondents Sample Component Active Duty Natl Guard Reserve 4327 (34.4)

3735 (29.7) 4509 (35.9) 3522 (44.3) 1866 (23.5) 2564 (32.3) 7849 (38.2) 5601 (27.3) 7073 (34.5) 24,000 (40) 16,000 (26.7) 20,000 (33.3) Branch Air Force Army Marines Navy 2431 (19.3) 7134 (56.8) 1236 (9.8) 1770 (14.1) 1902 (23.9)

4002 (50.3) 731 (9.2) 1317 (16.6) 4333 (21.1) 11136 (54.3) 1967 (9.6) 3087 (15.0) 11,648 (19.4) 32,754 (54.6) 6,794 (11.3) 8,804 (14.7) Total 12571 (61.2) 7952 (38.8) 20523 (100.0) 60,000 (100) Results Selected Demographic Variables by Deployment Status to Afghanistan/Iraq n (%)

Deployed Non-Deployed All Respondents Sample 2,823 (22.5) 4,122 (32.8) 3,697(29.4) 1,601 (12.7) 328 (2.6) 1,842 (23.1) 2,507 (31.5) 1,988 (25.0) 1,269 (16.0) 346 (4.4) 4,665 (22.7) 6,629 (32.3) 5,685 (27.7) 2,870 (14.0) 674 (3.3)

19,841 (33.1) 21,121 (35.2) 12,686 (21.1) 5,338 (8.9) 1,014 (1.7) Married or w/ partner Married /separated Single, never married 8,390 (66.7) 494 (3.9) 2,230 (17.7) 5,345 (67.2) 296 (3.7) 1,391 (17.5) 13,735 (66.9) 790 (3.9) 3,621 (17.6) N/A N/A N/A Divorced

Widowed Missing 1,382 (11.0) 38 (0.3) 37 (0.3) 12,571 (61.2) 861 (10.8) 27 (0.3) 32 (0.3) 7,952 (38.8) 2,243 (10.9) 65 (0.3) 68 (0.3) 20,523 (100.0) N/A N/A N/A 60,000 (100) Age 24-29 30-39 40-49

50-59 60+ Marital Status Total Results 32a. During military service did you experience any of the following events? Mechanism* Number (%) Deployed N=12,596 Non-Deployed N=7,965 a. Blast or Explosion 5,874 (47%) b. Motor vehicle , aircraft, or water trans. accident 2,940 (23%) c. Fragment or bullet wound above the shoulders 215 (1.7%) 961 (12%) 1,397 (18%) 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* Losing consciousness Being dazed, confused, or seeing stars** Not remembering the event

Concussion Head Injury None Number (%) Deployed N=9,780 1,012 (10.4%) 2,604 (27%) 735 (7.5%) 772 (7.9%) 848 (8.7%) 6,566 (67%) Non-Deployed N=5,248 590 (11%) 1,269 (24%) 343 (6.5%) 392 (7.5%) 447 (8.5%) 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* Memory problems or lapses Balance problems or dizziness Sensitivity to bright light Irritability Headaches Sleep problems Trouble concentrating Hearing problems No, none of the above Number (%) Deployed N=3,051 1,062 (35%) 783 (26%) 764 (25%) 1,343 (44%) 1,358 (45%) 1,489 (49%) 1,172 (38%) 1,175 (39%) 644 (21%) *Any positive response: Deployed = 77%; Non-deployed = 68%

Non-Deployed N=1,565 342 (22%) 366 (24%) 272 (17%) 384 (25%) 571 (37%) 527 (34%) 400 (26%) 289 (18%) 469 (30%) Results 33. In the past week, have you had any of the following? Symptoms in the Past Week* Memory problems or lapses Balance problems or dizziness Sensitivity to bright light Irritability Headaches Sleep problems Trouble concentrating Hearing problems No, none of the above Number (%)

Deployed N=2,355 926 (39%) 519 (22%) 594 (25%) 1,310 (56%) 1,107 (47%) 1,491 (63%) 1,114 (47%) 916 (39%) 183 (7.8%) *Any positive response: Deployed = 91%; Non-deployed = 91% Non-Deployed N= 1,061 339 (32%) 250 (24%) 231 (22%) 465 (44%) 493 (47%) 650 (61%) 454 (43%) 288 (27%) 102 (9.6%) 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 Results 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. 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) Males Total PTSD 1,811 Screen (14.4%) positive Non-deployed (N=7,942) Females Males Females (n=10,098) (n=2,479) Total (n=6,077) (n=1,865) 1,496 (14.8%) 536 (8.8%)

200 (10.7%) 315 (12.7%) 736 (9.3%) 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

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