analysis of va health care utilization among operation enduring freedom (oef) and operation iraqi...

Cumulative from 1st Quarter FY 2002 through 4th Quarter FY 2009

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Analysis of VA Health Care Utilization among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom

(OIF) Veterans

VA Office of Public Health and Environmental HazardsFebruary 2010


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Current DoD Roster of Recent Veterans

• Evolving roster development by DoD Defense Manpower Data Center (DMDC)

– In September 2003, DMDC developed an initial file of “separated” troops who had been deployed to the Iraqi and Afghan theater of operations using proxy files: Active Duty and Reserve Pay files, Combat Zone Tax Exclusion, and Imminent Danger Pay data.

– In September 2004, DMDC revised procedures for creating periodic updates of the roster and now mainly utilizes direct reports from service branches of previously deployed OEF (Operation Enduring Freedom) and OIF (Operation Iraqi Freedom) troops.

– Office of Public Health and Environmental Hazards is working with DMDC to improve the accuracy and completeness of the roster and the variables provided.


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Current DoD Roster of Recent Veterans

• Latest update of roster– Provided to Department of Veterans Affairs (VA) Environmental

Epidemiology Service on October 12, 2009

• Qualifications of DoD’s OEF/OIF deployment roster– Contains list of Veterans who have left active duty and does not include

currently serving active duty personnel– Does not distinguish OEF from OIF Veterans – Roster only includes separated OEF/OIF Veterans with out-of-theater

dates through August 2009– Beginning with the 3rd Quarter FY 2009 report, Veterans who received

health care but subsequently died in-theater are being included in the quarterly analysis. Because this is a cumulative report going back to 2002, and due to the duration of OEF/OIF and repeated deployments, a certain number of these Veterans may have accessed VA health care services

– The number of individuals who died in-theater through 4th Quarter FY 2009 is 4,898


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Updated Roster of OEF and OIF Veterans Who Have Left

Active Duty

• 1,094,502 OEF and OIF Veterans have left active duty and become eligible for VA health care since FY 2002

– 52% (573,404) Former Active Duty troops– 48% (521,098) Reserve and National Guard


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Use of DoD Roster of Veterans Who Have Left Active Duty

• This roster is used to check the VA’s electronic inpatient and outpatient health records, in which the standard ICD-9 diagnostic codes are used to classify health problems, to determine which OEF/OIF Veterans accessed VA health care as of September 30, 2009.

• The data available for this analysis are mainly administrative data obtained from Veterans’ VA medical records and are not based on a review of each patient record or a confirmation of each diagnosis. However, every clinical evaluation is captured in VA’s computerized patient record. The data used in this analysis are appropriate for health care planning purposes because the ICD-9 administrative data accurately reflect the need for health care resources.

• These administrative data have to be interpreted with caution because they only apply to those OEF/OIF Veterans who have accessed VA health care. These data do not represent all 1,094,502 OEF/OIF Veterans who have become eligible for VA health care since FY 2002 or the approximately 2.04 million troops who have served in the two theaters of operation since the beginning of the conflicts in Iraq and Afghanistan1.

1 As provided by the Armed Force Health Surveillance Center (Personal Communication), 01/20/2010


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Use of DoD Roster of Veterans Who Have Left Active Duty (2)

• Because VA health data are not representative of the Veterans who have not accessed VA health care, formal epidemiological studies are required to answer specific questions about the overall health of OEF/OIF Veterans.

• Analyses based on this updated roster are not directly comparable to prior reports because the denominator (number of OEF/OIF Veterans eligible for VA health care) and numerator (number of Veterans enrolling for VA health care) change with each update.

• This report presents data from VA’s health care facilities and does not include Vet Center data or DoD health care data.

• The following health care data are “cumulative totals” since FY 2002 and do not represent data from any single year.

• The numbers provided in this report should not be added together or subtracted to provide new data without checking on the accuracy of these statistical manipulations with VA’s Office of Public Health and Environmental Hazards.


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VA Health Care Utilization from FY 2002 through 2009 (4th Qtr.) among

OEF and OIF Veterans • Among all 1,094,502 separated OEF/OIF Veterans

– 46% (508,152) of total separated OEF/OIF Veterans have obtained VA health care

since

FY 2002 (cumulative total)

• 95% (481,619) of 508,152 evaluated OEF/OIF patients have been seen as outpatients only by VA and not hospitalized

• 5% (26,533) of 508,152 evaluated OEF/OIF patients have been hospitalized at least once in a VA health care facility


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VA Health Care Utilization for FY 2002-2009 (4th Qtr.) by Service Component

• 573,404 Former Active Duty Troops in DMDC roster

– 47% (271,988) have sought VA health care since FY 2002 (cumulative total)

• 521,098 Reserve/National Guard Members in DMDC roster

– 45% (236,164) have sought VA health care since FY 2002 (cumulative total)


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Comparison of VA Health Care Requirements

The cumulative total of 508,152 OEF/OIF Veterans utilized VA health care over approximately 8 years from FY 2002 through FY 2009 (4th Qtr.) represents about 9% of the 5.74 million individuals who received VA health care in any one year (total VA patient population of 5.74 million in FY 2009).


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VISN 1 VA New England Healthcare System 22,417 4.4VISN 2 VA Healthcare Network Upstate New York 14,244 2.8VISN 3 VA New York/New Jersey Healthcare System 19,301 3.8VISN 4 VA Stars & Stripes Healthcare System 24,405 4.8VISN 5 VA Capital Health Care System 16,392 3.2VISN 6 VA Mid-Atlantic Healthcare System 30,970 6.1VISN 7 VA Atlanta Network 38,892 7.7VISN 8 VA Sunshine Healthcare Network 39,835 7.8VISN 9 VA Mid-South Healthcare Network 29,195 5.8VISN 10 VA Healthcare System of Ohio 15,705 3.1VISN 11 Veterans in Partnership Healthcare Network 23,164 4.6VISN 12 VA Great Lakes Health Care System 27,451 5.4VISN 15 VA Heartland Network 20,837 4.1VISN 16 South Central VA Health Care Network 46,826 9.2VISN 17 VA Heart of Texas Health Care Network 36,029 7.1VISN 18 VA Southwest Healthcare Network 27,237 5.4VISN 19 VA Rocky Mountain Network 22,902 4.5VISN 20 VA Northwest Network 28,052 5.5VISN 21 VA Sierra Pacific Network 24,303 4.8VISN 22 VA Desert Pacific Healthcare Network 43,249 8.5VISN 23 VA Midwest Health Care Network 30,825 6.1

Frequency Distribution of OEF and OIF Veterans According to the VISN Providing the Treatment

OEF-OIF Veterans Treated at a VA Facility*

Treatment Site Frequency %

* Veterans can be treated in multiple VISNs. A Veteran was counted only once in any single VISN but can be counted in multiple VISN categories. The total number of OEF-OIF Veterans who received treatment (n = 508,152) was used to calculate the percentage treated in any one VISN.


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Demographic Characteristics of OEF and OIF Veterans Utilizing VA Health Care

% OEF/OIF Veterans(n = 508,152)

% OEF/OIF Veterans(n = 508,152)

Sex Unit Type

Male 88.1Active

Duty53.5

Female 11.9Reserve/

Guard46.5

Birth Year Cohort* Branch1980 – 1993 41.7 Air Force 12.11970 – 1979 27.9 Army 62.21960 – 1969 22.0 Marines 13.31950 – 1959 7.2 Navy 12.3

1926 – 1949 1.2Rank

Enlisted 91.3Officer 8.7

* 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 Veterans utilizing VA health care. This began with the 3rd Qtr FY 2009 report.


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Diagnostic Data

• Veterans of recent military conflicts have presented to VA with a wide range of medical and psychological conditions.

• Diagnoses have encompassed more than 8,000 discrete ICD-9 diagnostic codes.

• The three most common possible diagnoses of Veterans were musculoskeletal ailments (principally joint and back disorders), mental disorders, and “Symptoms, Signs and Ill-Defined Conditions.”

• As in other outpatient populations, the ICD-9 diagnostic category, “Symptoms, Signs and Ill-Defined Conditions,” was commonly reported. It is important to understand that this is not a diagnosis of a mystery syndrome or unusual illness. This ICD-9 code includes symptoms and clinical findings that are not coded elsewhere in the ICD-9. It is a diverse, catch-all category that is commonly used for the diagnosis of outpatient populations. It encompasses more than 160 sub-categories and primarily consists of common symptoms that do not have an immediately obvious cause during a clinic visit or isolated laboratory test abnormalities that do not point to a particular disease process and may be transient.


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Diagnosis (Broad ICD-9 Categories) Frequency Percent

Infectious and Parasitic Diseases (001-139) 68,569 13.5

Malignant Neoplasms (140-208) 5,809 1.1

Benign Neoplasms (210-239) 25,491 5.0

Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 135,250 26.6

Diseases of Blood and Blood Forming Organs (280-289) 14,342 2.8

Mental Disorders (290-319) 243,685 48.0

Diseases of Nervous System/ Sense Organs (320-389) 202,298 39.8

Diseases of Circulatory System (390-459) 94,671 18.6

Disease of Respiratory System (460-519) 116,308 22.9

Disease of Digestive System (520-579) 172,462 33.9

Diseases of Genitourinary System (580-629) 63,421 12.5

Diseases of Skin (680-709) 93,635 18.4

Diseases of Musculoskeletal System/Connective System (710-739) 265,450 52.2

Symptoms, Signs and Ill Defined Conditions (780-799) 233,443 45.9

Injury/Poisonings (800-999) 130,300 25.6

Frequency of Possible Diagnoses among OEF and OIF Veterans

*These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of September 30, 2009; 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 508,152; percentages add up to greater than 100 for the same reason.


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Frequency of Possible Mental Disorders among OEF/OIF Veterans since 20021

Disease Category (ICD 290-319 code)Total Number of

OEF/OIF Veterans2

PTSD (ICD-9CM 309.81)3 129,654

Depressive Disorders (311) 90,936

Neurotic Disorders (300) 74,559

Affective Psychoses (296) 52,982

Nondependent Abuse of Drugs (ICD 305)4 41,980

Alcohol Dependence Syndrome (303) 24,454Specific Nonpsychotic Mental Disorder due to Organic Brain Damage (310) 15,040

Special Symptoms, Not Elsewhere Classified (307) 14,531Sexual Deviations and Disorders (302) 12,382Persistent Mental Disorders due to Conditions Classified Elsewhere (294) 12,029

1 These are cumulative data since FY 2002. ICD diagnoses used in these analyses are obtained from computerized administrative data. Although diagnoses are made by trained health care providers, up to one-third of coded diagnoses may not be confirmed when initially coded because the diagnosis is provisional, pending further evaluation. 2 A total of 243,685 unique patients received a diagnosis of a possible mental disorder. A Veteran may have more than one mental disorder diagnosis and each diagnosis is entered separately in this table; therefore, the total number above will be higher than 243,685. 3 This row of data does not include information on PTSD from VA’s Vet Centers or data from Veterans not enrolled for VA health care. Also, this row does not include Veterans who did not receive a diagnosis of PTSD (ICD 309.81) but had a diagnosis of adjustment reaction (ICD-9 309).4 This category currently excludes 67,172 Veterans who have a diagnosis of tobacco use disorder (ICD-9CM 305.1) and no other ICD-9CM 305 diagnoses.


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Summary• Recent OEF and OIF Veterans are presenting to VA with

a wide range of possible medical and psychological conditions.

• Recommendations cannot be provided for particular testing or evaluation – Veterans should be assessed individually to identify all outstanding health problems.

• 46.4% of separated OEF/OIF Veterans have sought VA health care since 2002 compared to 45.8% in the last quarterly report three months ago. As in other cohorts of military Veterans, the percentage of OEF/OIF Veterans receiving health care from the VA and the percentage with any type of diagnosis will tend to increase over time as these Veterans increasingly continue to enroll for VA health care and to develop new health problems.


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Summary (2)

• Because the 508,152 OEF and OIF Veterans who have accessed VA health care were not randomly selected and represent just 28% of the approximately 2.04 million OEF/OIF Veterans1, they do not constitute a representative sample of all OEF/OIF Veterans.

• Reported diagnostic data are only applicable to the 508,152 VA patients – a population actively seeking health care -- and not to all OEF/OIF Veterans.

For example, the fact that about 48% of VA patient encounters were coded as related to a possible mental disorder does not indicate that approximately half of all recent Veterans are suffering from a mental health problem. Only well-designed epidemiological studies can evaluate the overall health of OEF/OIF Veterans.

1 As provided by the Armed Force Health Surveillance Center (Personal Communication), 01/20/2010


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Summary (3)• Rates of VA health care utilization by recent OEF/OIF Veterans

may be influenced by combat Veterans’ enhanced access to VA health care enrollment (in January 2008, this authority was extended from 2 years to 5 years post discharge) and exemption from copay charges for any health problem possibly related to their military service.

• Also, an extensive outreach effort has been developed by VA to inform these Veterans of their benefits, including the mailing of a personal letter from the VA Secretary to Veterans identified by DoD when they separate from active duty and become eligible for VA benefits.

• When a combat Veteran's enhanced health care eligibility expires, the Veteran will be moved to their appropriate priority group and charged all co-payments as applicable. If their financial circumstances place them in Priority Group 8, their enrollment in VA will be continued, regardless of the date of their original VA application.


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Follow-Up

• VA will continue to monitor the health care utilization of recent OEF/OIF Veterans using updated deployment rosters provided by DoD to ensure that VA tailors its health care and disability programs to meet the needs of this newest generation of Veterans.

analysis of va health care utilization among operation enduring freedom (oef) and operation iraqi...

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