Cardiac Events in the Central Command Area of Operations CENTCOM AOR Force Health Protection Confere

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Cardiac Events in the Central Command Area of
Operations (CENTCOM AOR) Force Health Protection
ConferenceAlbuquerque, New Mexico August 9,
2006

• Kathryn Stamps MPH1,2
• Nikki Jordan MPH2, Stephanie Morrison MPH1,2, CPT
  Roberto Marin PA2, MAJ Steven Tobler MD MPH2
• Oak Ridge Institute for Science and Education1
• US Army Center for Health Promotion and
  Preventive Medicine2

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BACKGROUND
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Cardiovascular Disease (CVD)

• In 2003, 71,300,000 or 1 in 3 American adults
  were diagnosed with 1 or more types of CVD.
• According to the American Heart Association
  Cardiovascular disease deaths (CVD) rank
• 1 among ages 65-74 -2 among ages 25-64
• Major risk factors include
• High Total Cholesterol -High Blood Pressure
• Smoking -Diagnosed Diabetes

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Pre-deployment Health Screening
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Casualty Data
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1 TRANSCOM Regulating and Command and Control
Evacuation System (TRAC2ES) includes 1st
CENTCOM TO EUCOM EVACUATION.
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LITERATURE REVIEW

• Filardo, et al. Unprotected Percutaneous Coronary
  Intervention is Safe and Effective for treating
  Unstable Angina in the Modern Warrior The
  Second Gulf War Experience at Landstuhl Regional
  Medical Center, Germany. Military Medicine, Vol.
  170, February 2005.
• Silverman, et al. Medical and Physical Readiness
  of the U.S. Army Reserves for Noble
  Eagle/Enduring Freedom/Iraqi Freedom
  Recommedations for Future Mobilizations.
  Military Medicine, Vol. 170, June 2005.
• Osswald, et al. Review of Cardiac Events in USAF
  Aviators. Aviation, Space, and Environmental
  Medicine, Vol. 67(11), November 1996.
• Wellford, et al. Changing Presentation of
  Coronary Heart Disease in an Inpatient Population
  within the U.S. Military Health Care System.
  Military Medicine, Vol. 158, September 1993.

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Objectives

• Describe cardiac conditions among military
  aeromedical evacuations from the CENTCOM AOR
• Describe cardiovascular disease trends among
  CENTCOM deployed
• Identify risk factors associated with CENTCOM
  cardiac outcomes
• Identify potential policy implications

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METHODS
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Military Health SystemEchelons of Care
Echelon 5
Echelon 4
Theater/Deployed Forces
Sustaining Base
Echelon 3
Echelon 2
Echelon 1
www.telemedicine.org
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Data Sources

• TRANSCOM Regulating and Command and Control
  Evacuation System (TRAC2ES)
• CENTCOM to EUCOM evacuations only
• Military Health System (MHS) MART (M2)
• Standard Inpatient Data Records (SIDR)
• Standard Ambulatory Data Records (SADR)
• Defense Manpower Data Center (DMDC)
• All CENTCOM Deployment Records

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Data Linking Methodology

• SSN
• TRAC2ES
• CENTCOM to EUCOM evacuations
• Evacuation or Ready Date
• SIDR and SADR records
• 1st Admission or visit following the TRAC2ES
  evacuation within 180 days of evacuation

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Surveillance Plan
Level III TRAC2ES Cardiac Cohort
Confirmed cardiac cases
Does not meet Cardiac Case definition
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TRAC2ES Cardiac Cohort

• All Circulatory System ICD-9 codes
• (390-459)
• Cardiovascular-related ICD-9 V-codes
• (V15.1, V17.3, V17.4, V71.7, V81.0, V81.1, V81.2)
• Cardiovascular-related ill-defined ICD-9 codes
• (785.0, 785.1, 785.2, 785.3, 785.50, 785.51,
  785.9, 780.2, 786, 786.02, 786.5, 786.51, 786.59)

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CASE DEFINITIONS(Final Outcomes of Interest)

• Level III or IV Diagnosis of CVD
• (includes MSMR burden of disease categories
  Essential hypertension, Ischemic, Rheumatic,
  Cerebrovascular, inflammatory, all other CVD)
• ICD-9 codes 401-439 440.9
• Level III or IV Diagnosis of Ischemic Heart
  Disease
• ICD-9 codes 410-414 426-426.9 427.4-427.5
  428-428.22 428.4 429.0-429.2, 429.9 440.9

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RESULTS
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Database LinkageOct 2001 Dec 2005
N333
Matching for all three databases n656
N782
N1,956
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Final Outcome CVD
Level III TRAC2ES Cardiac Cohort (suspect cardiac
evacuations) n2,415
CASE DEFINITION n1,215
Confirmed Level IV Cases n463
New Level IV Cases n274
Non-Confirmed Level III Cases n478
2005 CVD evacuation rate 1.6 CVD evacuations
per 1000 troops deployed to CENTCOM
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Final Outcome Ischemic Heart Disease
Level III TRAC2ES Cardiac Cohort (suspect cardiac
evacuations) n2,415
CASE DEFINITION n554
Confirmed Level IV Cases n 140
New Level IV Cases n 133
Non-Confirmed Level III Cases n 281
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Population Characteristics as of 31 Dec 2005
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Risk Analysis (Logistic Regression)
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Includes Level IV EUCOM facility inpatient and
outpatient records with any diagnoses of Ischemic
Heart Disease, (i.e. Primary or secondary dx
codes). Rates calculated using unclassified
data obtained from the 'Joint Chiefs of Staff,
Manpower and Personnel Directorate.
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DISCUSSION
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LIMITATIONS

• Data quality issues
• Accuracy
• Coding practices vary across data systems
  (TRAC2ES M2) and personnel entering the data
• CVD diagnosis at level III which were not
  confirmed at Level IV should be investigated
  further
• Completeness
• 13.7 or 333 suspect cases from our TRAC2ES
  cardio cohort were lost to follow-up may need to
  expand MTFs queried to improve data capture
• In theater cardiac events treated at lower levels
  of care were not captured therefore rates are
  underestimates
• Impact of pre-existing conditions could not be
  assessed
• Risk factor data (i.e. smoking history, BMI,
  family history) were not available

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Conclusion

• Due to data limitations, rates presented are
  conservative
• Risk factors noted (i.e. increased age, male
  gender) are consistent with the literature
• Additional risk factors included officer status,
  reserve or guard status, and Army affiliation

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Recommendations

• Pre-deployment training in medical systems and
  ICD9 coding doctrine
• Data Validation within source systems
• Expansion of study to include data from
  additional level III-V treatment centers
• Further study to determine
• Exposures
• Risk factors
• Pre-existing conditions
• Long-term outcomes

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Policy Implications

• Re-examine military age requirements
• Assess CVD pre-deployment screening practices,
  enrollment criteria, and risk factors across the
  Services
• Increase health education to promote
  heart-healthy lifestyle practices (e.g. smoking
  cessation)

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Questions?USACHPPM Directorate of Epidemiology
Disease Surveillance410-436-3534 DSN 584
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US Army Center for Health Promotion and
Preventive Medicine

• Mission To provide health promotion and
  preventive medicine leadership and services to
  counter environmental, occupational, and disease
  threats to health,
• fitness, and readiness in support of the National
  Military Strategy