Nikki Jordan, MPH

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Noise Induced Hearing Injury (NIHI) Among Army
Soldiers Deployed to the Central Command Area of
Operations (CENTCOM AOR)
Nikki Jordan, MPH Thomas Helfer, PhD Robyn Lee,
MS United States Army Center For Health
Promotion Preventive Medicine DoD Hearing
Conservation Work Group Meeting Sep 7, 2006
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Background
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Spring 2003-OIF
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Literature Review

• Hearing Loss is the most common and tinnitus is
  the third most common service-connected
  disability among veterans
• Fausti SA, et al. Hearing health and care The
  need for improved hearing loss prevention and
  hearing conservation practices. J Rehabil Res
  Dev. 2005 Jul-Aug 42(4 Suppl 2)45-62.
• Hearing loss is the fourth leading reason for
  medical referral for combatants routinely
  returning from their deployments. Approximately
  22 of 5000 post deployment Soldiers (OIF OEF)
  referred to audiologist had documented hearing
  loss.
• Schulz, TY. Troops Return with Alarming Rates
  of Hearing Loss. Hearing Health vol 203 Fall
  2004.
• Significantly higher rates of noise induced
  hearing loss observed among Army Soldiers seen at
  military Audiology clinics from April 2003
  through March 2004 whose visits were coded as
  post-deployment related as compared to those
  without this designation.
• Helfer TM, et al. Postdeployment Hearing Loss in
  U.S. Army Soldiers Seen at Audiology Clinics from
  April 1, 2003, Through March 31, 2004. AJA Vol
  14 161-168 Dec 2005.

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Initial Data Mining Study for NIHI Passive
SurveillanceHelfer TM, et al. Postdeployment
Hearing Loss in U.S. Army Soldiers Seen at
Audiology Clinics from April 1, 2003, Through
March 31, 2004. AJA Vol 14 161-168 Dec 2005.
Analysis Apr 03-Mar 04 Post-deployment
(V70.5 6) vs
Non-deployment
Sentinel NIHIs 388.11 Acoustic
trauma 388.12 Noise Induced Hearing
Loss 388.30 Tinnitus 384.20 Eardrum
perforation 389.8 H-3 hearing profile 389.9
H-4 hearing profile E928.1 noise exposure
Data Source Military Health System (MHS) Mart
(M2) outpatient records
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Helfer TM, et al. Postdeployment Hearing Loss in
U.S. Army Soldiers Seen at Audiology Clinics from
April 1, 2003, Through March 31, 2004. AJA Vol
14 161-168 Dec 2005.
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Media Misinterpretation
MISINTERPRETATION OF FINDINGS!!!
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Study Objectives

• Assess accuracy and completeness of the V70.56
  post-deployment ICD9 coding
• Assess utilization of NIHI relevant E-codes
• Determine NIHI prevalence among Soldiers
  following deployment to the CENTCOM area of
  operations (AOR) for ongoing operations (ONE,OEF,
  OIF)
• Comparison of NIHI rates among Soldiers post
  deployment to CENTCOM with rates among
  non-CENTCOM deployed Soldiers

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Methodology
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Fixing holes in the data

• Analytic Refinements
• Expansion of NIHI ICD9 codes
• Extension of timeframe
• Expansion of NIHI analysis beyond the audiology
  clinic population
• Inclusion of inpatient and purchased care data
• Validation with CENTCOM deployment rosters

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Data Sources

• MHS Mart (M2) FY 2003-2005
• Standard Inpatient Data Records (SIDR)
• Standard Ambulatory Data Records (SADR)
• Purchased Care Institutional
• Purchased Care Non-institutional
• DEERS personnel data
• Defense Manpower Data Center (DMDC) 09/11/2001
  12/31/2005
• Deployment rosters for CENTCOM deployments

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Additional NIHI Clinical Outcomes

• Additional Sentinel NIHIs
• 386.1/2 dizziness (vertigo)
• 780.4 balance/light-headedness NOS
• 385.23 dislocation of ossicles
• 384.81 healed TM perf
• 388.43 impairment auditory discrimination
• 389.02 conductive hearing loss eardrum
• 389.03 conductive hearing loss middle ear
• 386.40 labyrinthine fistula

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Final NIHI Outcome measures

• Based on incident diagnosis (primary or
  secondary) for each NIHI outcome or outcome
  group
• Acoustic trauma (388.11)
• Noise Induced Hearing Loss (NIHL) (38812)
• Tinnitus (388.30)
• Eardrum perforation (384.20)
• H-3/H4 hearing profile (389.8 389.9)
• Vertigo/Imbalance (386.1/2, 780.4)
• Other NIHI (385.23, 384.81, 388.43, 389.02,
  389.03, 386.40)
• Follow-up NIHI admissions/visits were excluded

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Final External Cause of Injury Codes
Additional ICD-9 E codes E993 wartime
explosives E979.2
IED E995 war operations Old
Favorites E923.8 explosives non war E928.1
exposure to noise usually steady noise
not impulse
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Results
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V70.56 E Code Assessment
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Assessment of Post Deployment Related Diagnosis
(ICD9 V70.56) Coding Accuracy for NIHI documented
episodes of Care, Army AD Eligible RSV/GRD
(FY2003 FY2005)
N430
N5739
Coding accuracy for non/pre-CENTCOM deployment
groups is difficult to assess because deployment
data for non-CENTCOM deployments (e.g. Desert
Strom, Bosnia, etc.) were not available
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NIHI Prevalence Estimates
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Summary

• While the ICD9 code for post deployment health
  outcomes proved to be very accurate, it was
  rarely used
• In general, monthly rates for acoustic trauma,
  and tinnitus were substantially higher for the
  post deployment cohort compared to the
  non-deployed cohort throughout the 3 FYs
  evaluated
• Post deployment rates for NIHL, eardrum
  perforations, vertigo, and other NIHI were higher
  during the first year of OIF, following which
  rates approached those observed among the
  non-deployed population
• We did not observe substantial increases in H3/H4
  profiles, which may have been influenced by
  increased pre-deployment screening or simply high
  baseline rates

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Limitations

• Rates produced are underestimates
• Limited Case Identification
• Post Deployment Cohort
• In theater NIHI diagnosis not available for
  inclusion
• VA data were not available
• Lack of Non-CENTCOM deployment data
• Non-Deployed/Pre-deployment cohort
• Inability to determine if conditions existed
  prior to FY2003 initial extraction of medical
  records
• Reduced case identification for Reserve/Guard
  members
• Inflated population estimates
• Data needed to determine total person time for
  our populations of interest was not available
• Inability to determine the influence of increased
  pre-deployment screening on observed
  non-deployment rates

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Future Analyses

• Supplemental analysis of FY2001 and FY2002
  medical data to determine baseline rates prior to
  the start of OIF
• Enhanced analyses through integration with other
  data sets (e.g. in theater medical data, VA,
  DMDC, DD2795/DD2796) are in the planning stages
• Perform stepwise refinements to NIHI reporting
  will be made IAW DOD Military Injury Metrics
  Working Group standards

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Questions?

• Contact information
• Nikki Jordan, MPH
• Nikki.Jordan_at_US.Army.mil
• Phone [phone] DSN 584-1001
• Tom Helfer, PHD
• E-mail Thomas.Helfer_at_.US.Army.mil
• Robyn Lee, MS
• Robyn.Lee2_at_ US.Army.mil