Operation Iraqi Freedom
Analysis of VA Health Care Utilization -- Report 7
VHA Office of Public Health and Environmental Hazards, July 22, 2004
Summary
· Among 168,528 veterans of Operation Iraqi Freedom who have separated from active military duty, 16% (27,571) have sought health care from the Department of Veterans Affairs (VA) since deployment.
· For another gauge of VA health care utilization, 7,916 Iraqi Freedom veterans had one or more VA healthcare visits in April 2004, which represents an average workload during that one month period of approximately 50 veterans treated in each of 158 VA hospitals.
· 57% of Iraqi Freedom veterans who received VA health care have been members of the Reserve/National Guard.
· Veterans of Operation Iraqi Freedom have presented to the VA with a wide range of both medical and psychological conditions, which have encompassed over 3,800 discrete diagnoses.
· The most common health problems of veterans of Operation Iraqi Freedom have been musculoskeletal ailments, principally joint and back disorders, and dental problems.
· The frequency of the diverse types of diagnoses received by these 27,571 veterans has not changed substantially since the last update of this report on May 19, 2004.
· Although health care utilization data does not represent a formal epidemiological study, no particular health problem stands out among Iraqi Freedom veterans at present. Consequently, recommendations cannot be provided for particular testing or evaluation; these war veterans should be assessed individually to identify all outstanding health problems.
· The Veterans Health Administration (VHA) will continue to monitor the health status of recent Iraqi war veterans using updated deployment lists provided by DoD to ensure that VA tailors its health care and disability programs to meet the needs of this newest generation of war veterans.
Lists of Recent War Veterans
VHA’s Environmental Epidemiology Service (EES-135) has been working with DoD to obtain a complete roster of recent combat veterans. To date, the DoD Defense Manpower Data Center (DMDC) has created a preliminaryfile of the Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) troops using Active Duty and Reserve Pay files, and Combat Zone Tax Exclusion and Imminent Danger Pay data fields. On September 22, 2003, DoD sent EES the first partial list of Iraqi war veterans who had “separated” from active duty but not the complete roster of deployed troops.
The eighth, most recent, update of these deployment lists was provided to EES on June 23, 2004. For the purposes of this analysis, all these lists were merged by EES to form a single roster of separated veterans who had participated in Operation Iraqi Freedom (Figure 1). EES has noted certain discrepancies in the data both within and between these deployment lists, which could affect some analyses of clinical care. DMDC plans to address these data discrepancies in future roster preparations.
The combined database provides basic military and demographic data on 168,528 unique service members who served in Operation Iraqi Freedom since October 1, 2003, and have been separated from active military service: 50,705 active duty and 117,823 Reserve or National Guard unit members (Tables 1 and 2). The DoD file did not include actual date of separation for everyone but the last out-of-theater date was March 2004, for active duty personnel and March 2004, for members of the Reserve/National Guard.
VA Health Care Utilization
Among all 168,528 separated Iraqi Freedom veterans, 27,571 (16.4%) had sought health care at a VA medical facility during fiscal years 2003 and 2004 (Table 3). Of those, 489 (0.3%) had been hospitalized at least once. Fifty-seven percent of veterans who received VA health care have been members of the Reserve/National Guard (Table 4). VISN 8 in Florida (VA Sunshine Healthcare Network) has seen the highest percentage (10.3%) of Iraqi Freedom veterans (Table 5).
The percentage of separated Iraqi Freedom veterans who had sought VA health care has continued to increase since the last report, which was based on the roster received on April 16, 2004, from 15% (21,021 of 139,778 separated veterans) to 16% (27,571 of 168,528 separated veterans). This increase reflects continued enrollment of Iraqi Freedom veterans for VA health care, which is available free of charge for two years following separation from active military service for any health problem possibly related to deployment.
As another gauge of VA health care utilization, in April 2004, 7,916 unique Iraqi Freedom veterans had one or more VA healthcare visits, which represents an average workload of approximately 50 veterans treated in each of 158 VA hospitals during that one month, or less than 2 veterans per day. For comparison, more than 4.5 million individuals received care in VA healthcare facilities in 2002. And VA's outpatient clinics registered approximately 46.5 million visits. The 27,571 Iraqi Freedom veterans who have received VA health care in FY 2003/2004 therefore represents 0.6% of the total number of military veterans VA provided care for in 2002.
Most Common Diagnoses Among Iraqi Freedom Veterans
Of note, evaluated Iraqi Freedom veterans are not representative of deployed military personnel in general but are more typical of young, active, healthcare-seeking populations. The following summary of diagnoses therefore does not represent an epidemiological study of all veterans recently deployed to Southwest Asia but does provide important clinical information about VA health care utilization of Operation Iraqi Freedom veterans.
Veterans of Operation Iraqi Freedom are presenting to the VA with a wide range of both medical and psychological conditions. A total of 3,890 discrete, ICD-9 coded diagnoses were needed to characterized this predominantly outpatient population seeking health care following deployment. No particular diagnosis stood out as unusual among this broad range of health problems (Tables 6-21).
The frequency of the types of diagnoses received by these 27,571 Iraqi Freedom veterans has not changed substantially since the previous analysis of 21,021 Iraqi Freedom veterans who had received VA health care. The most common, broad diagnostic categories are similar to those observed in the last report of May 19, 2004 (Table 6). Also, the most common specific diagnosis within broad ICD-9 categories changed little since the last report (Tables 7-21).
Among the 27,571 Iraqi Freedom veterans evaluated by the VA, the most frequent diagnoses involved the musculoskeletal system (Table 6). There were 8,134 veterans who received this diagnosis (ICD 710-739), which is very common in young, active, military populations. Within this diagnostic category, joint and back disorders were most often found (Table 19). The second most frequent category of diagnoses involved the Digestive System (ICD 520-579), with teeth and gum problems predominating (Tables 6 and 16).
In this population of veterans who served in a war zone and sought VA health care, 5,375 veterans were diagnosed with a mental health problem (Table 6). Within this group, PTSD was diagnosed among 1,641 Iraqi Freedom veterans (Table 12). It is critical to keep in mind that these statistics for mental health problems are preliminary and will change over time. Some troops may not have had an underlying mental health problem diagnosed at an initial clinical evaluation, and veterans may not develop mental health problems for months to years following wartime trauma.
Combined Deployment Lists, Health Care Utilization, and Diagnostic Tables
Table 1
Distribution of Separated Personnel Identified on the DoD Lists1 of Enduring Freedom (OEF) and Iraqi Freedom (OIF) Participants
By Operation and Component Type
Service Component Type
Military Operation Active Duty 2 Reserve/Guard 3 Total 4
Enduring Freedom 4,614 41,266 45,880
Male 4,129 37,272 41,401
Female 309 3,992 4,301
Unknown Gender 176 2 178
Iraqi Freedom 50,705 117,823 168,528
Male 45,177 105,393 150,570
Female 5,121 12,418 17,539
Unknown Gender 407 12 419
Total Veterans 5 53,200 141,486 194,686
Male 47,450 126,527 173,977
Female 5,309 14,946 20,255
Unknown 441 13 454
1 DMDC approved lists received September 22, 2003, November 21, 2003, December 22, 2003, February 12, 2004, March 22, 2004, April 16, 2004, May 18, 2004 and June 23, 2004 were combined to generate a composite list of unique veterans.
2 Active duty group includes last out-of-country dates through March 2004.
3 Reserve/Guard group includes last out-of-country dates through March 2004.
4 This table excludes 716 veterans on the composite list who died in-theater.
5 19,722 veterans served in both Operation Enduring Freedom and Operation Iraqi Freedom; therefore, the columns will not total correctly.
Table 2
Demographic and Military Characteristics of Separated Personnel Who Served in Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF)
Operation
Enduring Freedom Iraqi Freedom
(n=45,880) (n=168,528)
Characteristics # % # %
Sex
Male 41,401 90.2 150,570 89.3
Female 4,301 9.4 17,539 10.4
Unknown 178 0.4 419 0.3
Race/ethnicity
White 35,387 77.1 118,978 70.6
Black 5,367 11.7 23,366 13.8
Hispanic 2,352 5.1 9,261 5.5
Others 2,066 4.5 8,489 5.0
Unknown 708 1.5 8,434 5.0
Age Group
< 20 years 23 0.1 1,062 0.6
20-29 12,946 28.2 85,228 50.6
30-39 15,447 33.7 43,363 25.7
≥40 17,161 37.4 37,958 22.5
Unknown 303 0.7 917 0.5
Branch
Air Force 25,142 54.8 42,395 25.2
Army 18,459 40.2 74,989 44.5
Coast Guard 36 0.1 682 0.4
Marine 361 0.8 23,988 14.2
Navy 1,882 4.1 26,474 15.7
Unit Type
Active Duty 4,614 10.1 50,705 30.1
Reserve/Guard 41,266 89.9 117,823 69.9
Rank
Enlisted 37,872 82.5 146,615 87.0
Officer 8,008 17.5 21,913 13.0
Combined data received through June 23, 2004, provided to VA by DMDC. Troops who died in country are excluded from these data.
Table 3
FY 2003-2004 VA Hospitalizations and Outpatient Visits
As of June 28, 2004, for 168,528 Iraqi Freedom Veterans Identified
On the Combined DoD Deployment List
Iraqi Freedom Veterans
(n = 168,528)
Treatment Category Frequency %
Ever evaluated by VA during FY 2003/04
Yes 27,571 16.4 1
No 140,957 83.6
Inpatient Stays Only:
Hospitalized at Least Once at a
VAMC during FY 2003/04
Yes 489 0.3 1
No 168,039 99.7
Number of Times Hospitalized at a
VAMC during FY 2003/04
1 409 83.6 2
2 60 12.3
3+ 20 4.1
(Mean Number of Hospitalizations at
VA during FY 2003/04 = 1.2)
Outpatient Visits Only:
Seen as an Outpatient at VA
at Least Once during FY 2003/04
Yes 27,556 16.4 1
No 140,972 83.6
Number of Days Seen as an Outpatient
during FY 2003/04
1 9,143 33.2 3
2-10 16,153 58.6
11+ 2,260 8.2
(Mean Number of Visits to VA for
Outpatient Treatment during FY 2003/04 = 4.3)
______
1 Percent based on total number of eligible veterans (168,528)
2 Percent based on total number of hospitalized veterans (489)
3 Percent based on total number of veterans with one or more outpatient visits (27,556)
Table 4
Demographic and Military Characteristics of Separated Personnel Who Served in Operation Iraqi Freedom (OIF) and Received VA Healthcare in
FY 2003-2004
Iraqi Freedom Veterans
Evaluated at a VA Facility
(n=27,571)
Characteristics # %
Sex
Male 23,864 86.6
Female 3,704 13.4
Unknown 3 0.0
Race/ethnicity
White 17,570 63.7
Black 4,782 17.3
Hispanic 2,278 8.3
Others 1,487 5.4
Unknown 1,454 5.3
Age Group
< 20 years 117 0.4
20-29 14,429 52.3
30-39 6,194 22.5
≥40 6,812 24.7
Unknown 19 0.1
Branch
Air Force 3,794 13.8
Army 15,854 57.5
Coast Guard 24 0.1
Marine 4,162 15.1
Navy 3,737 13.6
Unit Type
Active Duty 11,809 42.8
Reserve/Guard 15,762 57.2
Rank
Enlisted 25,293 91.7
Officer 2,278 8.3
Table 5
Frequency Distribution of Iraqi Freedom Veterans According to the VISN Providing the Treatment
Iraqi Freedom Veterans
Treated at a VA Facility
Treatment Site Frequency1 %2
VISN 1 VA New England Healthcare System 1,231 4.5
VISN 2 VA Healthcare Network Upstate New York 855 3.1
VISN 3 VA New York/New Jersey Healthcare System 1,254 4.5
VISN 4 VA Stars & Stripes Healthcare System 1,345 4.9
VISN 5 VA Capital Health Care System 587 2.1
VISN 6 VA Mid-Atlantic Healthcare System 950 3.4
VISN 7 VA Atlanta Network 1,620 5.9
VISN 8 VA Sunshine Healthcare Network 2,844 10.3
VISN 9 VA Mid-South Healthcare Network 1,805 6.5
VISN 10 VA Healthcare System of Ohio 609 2.2
VISN 11 Veterans in Partnership Healthcare Network 856 3.1
VISN 12 VA great Lakes Health Care System 2,287 8.3
VISN 15 VA Heartland Network 811 2.9
VISN 16 South Central VA Health Care Network 2,176 7.9
VISN 17 VA Heart of Texas Health Care Network 1,358 4.9
VISN 18 VA Southwest Healthcare Network 1,530 5.5
VISN 19 VA Rocky Mountain Network 1,003 3.6
VISN 20 VA Northwest Network 1,089 3.9
VISN 21 VA Sierra Pacific Network 1,006 3.6
VISN 22 VA Desert pacific Healthcare Network 2,701 9.8
VISN 23 VA Midwest Health Care Network 981 3.6
1 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.
2 The total number of OIF veterans who received treatment (n=27,571) was used to calculate
the percentage treated in any one VISN.
Table 6
Diagnoses by Broad ICD-9 Categories for the 27,571 Iraqi Freedom Veterans Evaluated at a VA Healthcare Facility During FY 2003-20041
Iraqi Freedom Veterans
(n = 27,571)
Diagnosis
(ICD-9 Categories) Frequency 2 %
Infectious and Parasitic Diseases 1,888 6.9
(001-139)
Malignant Neoplasms (140-208) 153 0.6
Benign Neoplasms (210-239) 473 1.7
Diseases of Endocrine/Nutritional/ 2,666 9.7
Metabolic Systems (240-279)
Diseases of Blood and Blood 275 1.0
Forming Organs (280-289)
Mental Disorders (290-319) 5,375 19.5
Diseases of Nervous System/ 5,311 19.3
Sense Organs (320-389)
Diseases of Circulatory System 2,635 9.6
(390-459)
Disease of Respiratory System 3,505 12.7
(460-519)
Disease of Digestive System 6,788 24.6
(520-579)
Diseases of Genitourinary System 1,674 6.1
(580-629)
Diseases of Skin (680-709) 2,520 9.1
Diseases of Musculoskeletal System 8,134 29.5
Connective System (710-739)
Symptoms, Signs and Ill Defined 5,674 20.6
Conditions (780-799)
Injury/Poisonings (800-999) 3,195 11.6
1 Hospitalizations and outpatient visits as of 6/28/04.
2 Veterans can have multiple diagnoses with each healthcare encounter. However, a veteran is counted only once in any single Diagnostic Category but can be counted in multiple categories.