Aaron I Schneiderman, PhD, MPH, RN Acting Director, Environmental Epidemiology Service

1. 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

2. Acknowledgments Shannon Barth Steven Coughlin Stephanie Eber Erick Ishii Han Kang Clare Mahan Michael Peterson

3. 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

4. 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

5. Updated Roster 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.

6. 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/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.

7. 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) • 606,421Reserve/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

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.

9. Frequency of Diagnoses* among 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.

10. OEF, 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.

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.

12. 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.

13. 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 theater • Immediate symptoms post-injury • Persistent symptoms

14. 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

15. 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)

16. 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?

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

18. 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

19. 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%)

20. Gender 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

21. 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%)

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. Results

29. Results

30. Results 32a. During military service did you experience any of the following events? *Any positive response: Deployed = 78%; Non-deployed = 66%

31. Results 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%

32. Results 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%

33. Results 33. In the past week, have you had any of the following? *Any positive response: Deployed = 91%; Non-deployed = 91%

34. 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

35. 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

36. 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.

37. 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

38. 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