Health on the Homefront: TRAUMATIC BRAIN INJURY SURVEILLANCE, DEPARTMENT OF THE NAVY, SAILORS AND MARINES IN VIRGINIA, 2008-2018 Jean Slosek, MS, Epidemiologist Deployment Health Division, Epidemiology Data Center Department (EDC), Navy and Marine Corps Public Health Center, Department of the Navy ACKNOWLEDGEMENTS: Dagny B. Magill, MPH (EDC Epidemiologist) Tina M. Luse, MPH (EDC Deployment Division Head, Epidemiologist) Vo Vang, MSc (EDC Programmer) Viann N. Nguyen, MPH (EDC ORISE Fellow Epidemiologist) Serah Iheasirim, Dual-MPH,SSGB (EDC ORISE Fellow Epidemiologist) DISCLAIMER: The views expressed in this session are those of the presenter(s) and do not necessarily reflect the official policy or position of the U.S. Government or the Commonwealth of Virginia. The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U. S. Government. CONFLICT OF INTEREST DISCLOSURE: Jean Slosek, M.S. has no real or apparent conflicts of interest to report. Navy and Marine Corps Public Health Center 1 1
Overview What is the Deployment Health Division, EDC? What is traumatic brain injury (TBI)? What is TBI surveillance and why does EDC do it? How does the EDC do TBI surveillance for the Department of the Navy (DON)? Methods TBI surveillance data for active duty (AD) Sailors and Marines (examples from TBI surveillance) Conference-specific TBI data: TBI surveillance data for Virginia residents, AD Sailors and Marines TBI treated in fixed military treatment facilities (MTFs) in Virginia Navy and Marine Corps Public Health Center 2 Background What is the EpiData Center (EDC)? Created in 2005 Provides epidemiologic services to Department of the Navy customers 5 product lines: Communicable Disease Clinical Epidemiology Occupational/Environmental Epidemiology Deployment Health IT Navy and Marine Corps Public Health Center 3 2
Background What is traumatic brain injury (TBI)? In the U.S. Military Health System (MHS), traumatic brain injury (TBI) is defined as traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event: any period of loss of or decreased level of consciousness; any loss of memory for events immediately before or after the injury; any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.); neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient; intracranial lesion. Source: Memorandum from the Assistant Secretary of Defense (Health Affairs). Traumatic brain injury: definition and reporting, dated 1 Oct 2007. U.S Department of Defense, Washington, DC., In AFHSC Surveillance Case Definitions FINAL October 2011. Navy and Marine Corps Public Health Center 4 Background What is TBI surveillance? Public health surveillance is the routine analysis and reporting of summary data over time for a particular disease or type of injury. For TBI surveillance this may include Number of TBI new cases (incidence) Incidence rates (new TBI cases per population) Information on follow-up visits or total encounters Prevalence (number of people with TBI) Information on specific populations (for example by service branch, age, or sex) Information over time (months, years, cumulative totals) Navy and Marine Corps Public Health Center 5 3
Background Why does the Deployment Health Division, EDC do TBI surveillance? TBI is considered a signature injury for the war in Iraq and Afghanistan, affecting about 20% of injured troops. a Blasts from improvised explosive devices (IEDs) are a common cause of TBI in military personnel during combat (almost never seen in civilians) an estimated 60% of all blast injuries result in TBI. b Other TBI risks include motor vehicle crashes, sports, falls, and fights. TBI affects force readiness. Even mild TBI requires adequate rest to recuperate. TBI may require medical evacuation if severe enough or if symptoms not resolved. a. Defense Veterans Brain Injury Center, DVBIC Brainwaves, Winter 2009 b. Warden, D. L., Ryan, L. M., Helmick, K. M., Schwab, K., French, L., Lu, W., et al. (2005). War neurotrauma: the Defense and Veterans Brain Injury Center (DVBIC) experience at Walter Reed Army Medical Center (WRAMC). Journal of Neurotrauma, 22(10), 1178. Navy and Marine Corps Public Health Center 6 Background Military TBI surveillance methods are very different from civilian methods. What are differences in how the Centers for Disease Control and Prevention (CDC) and the DON do TBI surveillance? Data sources Populations Access to care TBI surveillance cases definition, including diagnosis codes Timeliness of data availability Navy and Marine Corps Public Health Center 7 4
Figure 1: TBI Data Sources, Centers for Disease Control and Prevention, 2002-2006 3% 16% 81% Source: Faul M, Xu L, Wald MM, Coronado V. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths, 2002 2006. Atlanta, Georgia: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010, Figure 1: Estimated Average Annual Number of Traumatic Brain Injury Related Emergency Department Visits, Hospitalizations, and Deaths, United States, 2002 2006 Navy and Marine Corps Public Health Center 8 Figure 2: TBI Data Sources, TBI New Cases (Incidence), AD DON, 2008-2013 Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), and Theater Medical Data Store (TMDS). Navy and Marine Corps Public Health Center 9 5
Figure 3: Population Distribution by Age, Total US Population and AD DON Percent of Total Population Data are from the US Census Bureau (single year population estimates, July 2012) and DMED (DON) averages for 2004-2012. Percentage calculations by the EpiData Center Department. Prepared by the EpiData Center Department, Navy and Marine Corps Public Health Center on 06 August 2013. Navy and Marine Corps Public Health Center 10 Table 1: Civilian vs. DON: Population Characteristics Navy and Marine Corps Public Health Center 11 6
Civilian vs. DON: TBI Surveillance Case Definitions United States Civilian TBI surveillance: Focuses on cause of injury and intent for TBI (requires E-codes or ICD-10 codes). Except for ER data, only includes data when information is available on the injury that caused the TBI. Fewer diagnosis codes are used. Not timely (death data usually not available for two or more years after event; hospital and ER data may also be distant from when TBI first occurred). AD DON TBI surveillance: E-codes are not widely available in data sources used. TBI case definition includes encounters without information on the injury event that caused the TBI. All diagnosis fields used (up to 20). Most TBI incidence are identified using outpatient data. Includes people whose first encounter with a TBI diagnosis was post-concussive syndrome. Timely outpatient and theater data are available weekly, hospital data is available monthly. Over 80% of TBIs in the military occur in a non-deployed setting a a. Source: DoD Worldwide Numbers for TBI, http://www.dvbic.org/dod-worldwide-numbers-tbi Navy and Marine Corps Public Health Center 12 Table 2: Civilian vs. US Military (including DON): Comparison of TBI Surveillance Case Definition a a. There are other (minor) discrepancies in list of TBI codes used. b. Faul M, Xu L, Wald MM, Coronado V. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths, 2002-2006. Atlanta, Georgia: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010. c. AFHSC Surveillance Case Definitions, FINAL October 2011. Navy and Marine Corps Public Health Center 13 7
TBI Surveillance Case Definition: DON Case Definition For surveillance purposes, a case of TBI is defined as: One inpatient or outpatient medical encounter, with any of the defined ICD-9-CM diagnosis codes for TBI in any diagnostic position. a Incidence Rules For individuals who meet the case definition: The incident date is the date of the first inpatient or outpatient medical encounter that includes a diagnosis of TBI. An individual is considered an incident case only once per lifetime. a. Source: Armed Forces Public Health Surveillance Center (AFPHSC), TBI surveillance case definitions, FINAL October 2011. http://afhsc.army.mil/viewdocument?file=casedefs/web_13_neurology_apr12.pdf Navy and Marine Corps Public Health Center 14 Figure 4: Timeline for TBI Surveillance in DON INJURY OCCURS Initial visit in Theater or Military Treatment Facility (MTF) diagnosed as TBI TBI surveillance begins (Incidence case date) Navy and Marine Corps Public Health Center 15 8
Methods: Strengths What are the strengths of DON TBI surveillance? TBI surveillance data is timely Inpatient data from any US fixed military treatment facility (MTF) worldwide is available and updated monthly, from 2002 to present. Ambulatory data from any MTF worldwide is available and updated weekly, from 2002 to present. Inpatient and ambulatory data in theater is available and updated weekly, from 2008 to present (includes shipboard facilities, battalion aid stations, or other in-theater facilities). Ambulatory data include both ER and outpatient appointments. Includes TBI severity (mild to severe), based on ICD-9-CM and V-codes. Can be broken down by place of residence or treatment facility TBI surveillance anywhere in the world, if treated in theater or at an MTF Data collection is standardized in the data sources used by DON for TBI surveillance Navy and Marine Corps Public Health Center 16 Methods: Limitations What are the limitations of DON TBI surveillance? Due to data source changes, ambulatory data before 1 January 2012 have four diagnosis fields, and data after this date have ten. Diagnoses in medical encounters depend on correct ICD-9-CM coding practices. Use of E-codes is limited, so cause of injury and intent not reported. Data for medical surveillance are considered provisional and medical case counts may change if the record is updated after the report is generated. In many cases, a lag time exists between the injury event and the screening or diagnosis of TBI cases. No TBI data from shipboard facilities, battalion aid stations, or in-theater facilities prior to 2008; some data may be missing from some shipboard facilities after that year. Navy and Marine Corps Public Health Center 17 9
TBI Surveillance in DON: Examples from the TBI Surveillance Data for AD Sailors and Marines from TBI Monthly Report, TBI Annual Report, and TBI Metrics for the Wounded, Ill, and Injured (WII) Program Navy and Marine Corps Public Health Center 18 Figure 5: Traumatic Brain Injury Cases, Active Duty Department of the Navy (AD DON), 2008-2013 Note: Analyses were restricted to patients without missing values. Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), and Theater Medical Data Store (TMDS). Navy and Marine Corps Public Health Center 19 10
Figure 5: Traumatic Brain Injury Cases, Active Duty Department of the Navy (AD DON), 2008-2013 Note: Analyses were restricted to patients without missing values. Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), and Theater Medical Data Store (TMDS). Navy and Marine Corps Public Health Center 20 Figure 5: Traumatic Brain Injury Cases, Active Duty Department of the Navy (AD DON), 2008-2013 Note: Analyses were restricted to patients without missing values. Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), and Theater Medical Data Store (TMDS). Navy and Marine Corps Public Health Center 21 11
Figure 6: TBI Cases, AD Navy and Marines, January 2013 January 2014, by Service Branch Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), and Theater Medical Data Store (TMDS). Navy and Marine Corps Public Health Center 22 Figure 7: TBI Incidence Rate (per 100,000), AD Navy and Marines, January 2013 January 2014 Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), Theater Medical Data Store (TMDS), and Defense Manpower Data Center (DMDC). Navy and Marine Corps Public Health Center 23 12
Figure 8: Percent of TBI Cases with Follow-up, AD Navy and Marines, January 2013-January 2014, by TBI Severity Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), and Theater Medical Data Store (TMDS). Navy and Marine Corps Public Health Center 24 Figure 9: TBI New Cases (Incidence), AD DON, by TBI Severity and Year, 2008-2013 Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), and the Theater Medical Data Store (TMDS). Navy and Marine Corps Public Health Center 25 13
Figure 10: TBI New Cases (Incidence), AD DON, Age-Specific Rate (per 100,000), by Year 2008-2013 Note: Analyses were restricted to patients without missing values. Age-specific incidence rates are the number of new cases in a given age group, per 100,000 service members in that same age group. Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), Theater Medical Data Store (TMDS), and Defense Medical Epidemiology Database (DMED). Prepared by the EpiData Center Department, Navy and Marine Corps Public Health Center on 06 May 0214. Navy and Marine Corps Public Health Center 26 Other TBI Surveillance Activities: TBI Incident Cases Data in Force Health Reports The TBI case database is updated monthly and shared with the team that prepares comprehensive Force Health Surveillance Reports (FHSR) which include a wide range of data shared with Navy and Marine Corps commands. TBI Rosters Special requests for TBI data that may include personal identifiers. As such, access to TBI rosters is restricted. TBI Surveillance Special Projects Long-term studies intended to improve TBI surveillance in DON. TBI Taskers Data requested by our customers that is not available through our routine reports. Typically these are requests for TBI surveillance data with a tight deadline. Navy and Marine Corps Public Health Center 27 14
Conference-Specific TBI Surveillance Data: TBI in AD DON Virginia Residents and TBI Surveillance in Virginia MTFs Navy and Marine Corps Public Health Center 28 Figure 11: TBI Cases, Virginia Residents in DON, January 2013-January 2014, by Service Branch Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), and Theater Medical Data Store (TMDS). Navy and Marine Corps Public Health Center 29 15
Figure 12: TBI Incidence Rate (per 100,000), Virginia Residents in DON, January 2013-January 2014 Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), Theater Medical Data Store (TMDS), and Defense Manpower Data Center (DMDC). Prepared by the EpiData Center Department, Navy and Marine Corps Public Health Center on 06 May 2014 Navy and Marine Corps Public Health Center 30 Figure 13: Percent of TBI Cases with Follow-up, Virginia Residents in DON, January 2013-January 2014 Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), and Theater Medical Data Store (TMDS). Navy and Marine Corps Public Health Center 31 16
Figure 14: TBI New Cases (Incidence), Virginia Residents in DON, by TBI Severity and Year, 2008-2013 Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), Theater Medical Data Store (TMDS), and Defense Manpower Data Center (DMDC). Navy and Marine Corps Public Health Center 32 Figure 15: Average TBI Rates Compared: DON and Virginia Residents in DON, 2008-2013 Note: Analysis was restricted to patients without missing values. Incidence rates are the number of new cases in each group per 100,000 service members in each group. Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), Theater Medical Data Store (TMDS), and Defense Manpower Data Center (DMDC). Navy and Marine Corps Public Health Center 33 17
Figure 16: New TBI Cases (Incidence), AD Navy and Marines, First Diagnosed and Treated in Virginia MTFs, January 2013- January 2014 Data are from the Standard Inpatient Data Record (SIDR), Standard Ambulatory Data Record (SADR), Comprehensive Ambulatory/Professional Encounter Record (CAPER), Theater Medical Data Store (TMDS), and Defense Manpower Data Center (DMDC). Navy and Marine Corps Public Health Center 34 Conclusions: TBI surveillance in DON and other military is different from civilian TBI surveillance. TBI surveillance in DON, done by EDC, can be customized to the special needs of the DON. AD Sailors and Marines have risks for TBI related to their deployment experience, but also have risks for TBI common to civilians. Most TBI in DON and the US military is classified as mild TBI, with good prospects for recovery. Navy and Marine Corps Public Health Center 35 18
Contact Information epi@nmcphc.med.navy.mil 757.953.0700 EpiData Center Department Navy and Marine Corps Public Health Center 620 John Paul Jones Circle, Suite 1100 Portsmouth, VA 23708 36 QUESTIONS? 19