Medical Encounter Data Research Articles

Investigation of a transient increase in omphalocele prevalence in a birth cohort of TRICARE beneficiaries.

The Department of Defense Birth and Infant Health Research (BIHR) program leverages medical encounter data to conduct birth defect surveillance among infants born to military families. Omphalocele is a major abdominal wall defect with an annual prevalence of ~2 per 10,000 births in BIHR data, but an unexpected increase was observed during 2017-2019, reaching 6.4 per 10,000 births in 2018. To investigate this transient increase in prevalence, this study aimed to validate the omphalocele case algorithm among infants born 2016-2021. Omphalocele cases were identified by ICD-10 code Q79.2 (exomphalos) on one inpatient or two outpatient infant encounter records and validated using parental and infant electronic health records. Characteristics of true and false positive cases were assessed using bivariate analyses and compared over time. Of 638,905 live births from 2016 to 2021, 230 met the ICD-10 case definition for omphalocele; 138 (60.0%) cases were eligible for validation, of which 68 (49.3%) were true positives. The geometric mean time from birth to first ICD-10 omphalocele diagnosis was 1.1 (standard error [SE] 0.1) days for true positives and 11.9 (SE 3.1) days for false positives. Among the 70 false positives, 36 (51.4%) were cases of confirmed umbilical hernia; rates of umbilical hernia and delayed omphalocele diagnoses (>30 days after birth) were elevated among false positives during 2017-2019. Higher misuse of ICD-10 code Q79.2 during 2017-2019 likely influenced the associated increase in omphalocele prevalence. Timing of diagnosis should be considered for omphalocele case definitions using medical encounter data.

Treatment of pancreatic adenocarcinoma in relation to survival in the U.S. Military Health System

BackgroundPancreatic cancer has a high case fatality and relatively short survival after diagnosis. Treatment is paramount to improving survival, but studies on the effects of standard treatment by surgery or chemotherapy on survival in U.S. healthcare settings is limited. Further, variability in access to care may impact treatment and outcomes for patients. We aimed to assess the relationship between standard treatment(s) and survival of pancreatic adenocarcinoma in a population with access to comprehensive healthcare. MethodsWe used the Military Cancer Epidemiology (MilCanEpi) database, which includes data from the Department of Defense cancer registry and medical encounter data from the Military Health System (MHS), to study a cohort of 1408 men and women who were diagnosed with pancreatic adenocarcinoma between 1998 and 2014. Treatment with surgery or chemotherapy in relation to overall survival was examined in multivariable time-dependent Cox regression models. ResultsOverall, 75 % of 441 patients with early-stage and 51 % of 967 patients with late-stage pancreatic adenocarcinoma received treatment. In early-stage disease, surgery alone or surgery with chemotherapy were both associated with statistically significant 52 % reduced risks of death, but chemotherapy alone was not. In late-stage disease, surgery alone, chemotherapy alone, or both surgery and chemotherapy significantly reduced the risk of death by 42 %, 25 %, and 52 %, respectively. ConclusionsOur findings from the MHS demonstrate improved survival after treatment with surgery or surgery with chemotherapy for early- or late-stage pancreatic cancer and after chemotherapy for late-stage pancreatic cancer. In the era of immunotherapy and personalized medicine, further research on treatment and survival of pancreatic cancer in observational settings is needed.

Medical Evaluation Readiness Information Toolset (MERIT): Developing a Data-driven Decision Support Tool to Augment Complex Clinical Decisions.

Medical readiness continues to be a significant concern for the military. DoD policy directs medical authorities to refer service members to the Disability Evaluation System (DES) when the course of further recovery is relatively predictable or within 1 year of diagnosis, whichever is sooner. The Medical Evaluation Readiness Information Toolset (MERIT) is an application that leverages artificial intelligence within a clinical decision support tool to provide clinicians with predictions of a service member's likelihood of referral to the DES for the top 24 medical conditions that result in separation from the service, which represent more than 90% of all referral cases to the DES since 2000. Data spanned 19 years and contained records for over 3 million army service members. The MERIT team incorporated a novel approach using a Gamma window function to weight recent medical data more than older medical data in the creation of a "Disease Severity Index" (DSI) that summarized the progression of a health deterioration process per medical condition code. Time-dependent medical encounter data were aggregated into an individual-level DSI. The identified features including the DSI were used in logistic regression and random forest models to predict whether a service member is likely to be referred to the DES. Models were constructed for each of the top 24 unfitting medical conditions. MERIT produced a set of high-performing classification models with area under the receiver operating characteristics curves across all conditions exceeding 0.919 using logistic regression for all conditions. This project demonstrated with a high degree of accuracy that MERIT, using a combination of ICD codes and personnel records, can be used to develop an individual risk profile for each service member.

MilCanEpi: Increased Capability for Cancer Care Research in the Department of Defense.

The Military Health System (MHS) of the US Department of Defense (DoD) provides comprehensive medical care to over nine million beneficiaries, including active-duty members, reservists, activated National Guard, military retirees, and their family members. The MHS generates an extensive database containing administrative claims and medical encounter data, while the DoD also maintains a cancer registry that collects information about the occurrence of cancer among its beneficiaries who receive care at military treatment facilities. Collating data from the two sources diminishes the limitations of using registry or medical claims data alone for cancer research and extends their usage. To facilitate cancer research using the unique military health resources, a computer interface linking the two databases has been developed, called Military Cancer Epidemiology, or MilCanEpi. The intent of this article is to provide an overview of the MilCanEpi data system, describing its components, structure, potential uses, and limitations.

Validation of diagnosis codes for chorioamnionitis in medical encounter data, 2013-2018.

Chorioamnionitis refers to intrauterine infection/inflammation that can be diagnosed clinically or from laboratory testing. This study aimed to validate chorioamnionitis International Classification of Diseases (ICD) codes using reference standards for clinical and histologic cases. Department of Defense Birth and Infant Health Research program data identified a cohort of live deliveries at two United States military hospitals from 2013 to 2018. Deliveries were screened for chorioamnionitis using ICD codes from maternal delivery records; a sample of screen positive and negative deliveries was selected for chart review. Primary analyses validated deliveries using a reference standard for clinical chorioamnionitis; secondary analyses employed a reference standard that also included histologic cases, but were limited by temporal differences in availability of laboratory data. Sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values were calculated with 95% confidence intervals (CIs). Overall, 1857 deliveries (465 screen positive, 1392 screen negative) were eligible for analysis and 336 met the reference standard for clinical chorioamnionitis, yielding a PPV of 0.68 (95% CI 0.63-0.72) and sensitivity of 0.76 (95% CI 0.72-0.81). In secondary analyses, 390 deliveries met the reference standard for clinical or histologic chorioamnionitis, resulting in an overall PPV of 0.75 (95% CI 0.71-0.79); in 2018, when more laboratory results were available, the PPV was 0.91 (95% CI 0.84-0.97). NPV and specificity were ≥0.97 across reference standards. Chorioamnionitis ICD codes exhibited moderate correlation with clinical disease, suggesting challenges in using medical encounter data to isolate clinical cases from those only identified through laboratory testing.

MDS-094 Characteristics and Management of Medicare Beneficiaries With Advanced Systemic Mastocytosis

Advanced systemic mastocytosis (AdvSM) (subtypes: aggressive SM, SM with associated hematological neoplasm, mast cell leukemia) is a rare clonal mast cell neoplasm driven by the KIT D816V mutation. Uncontrolled proliferation, accumulation, and activation of mast cells result in severe symptoms in various organ systems, making SM difficult to diagnose. Clinical guidelines recommend comprehensive testing and specialist care management. To describe AdvSM patient characteristics and use of healthcare services before AdvSM diagnosis in the US Medicare population. Design, Patients, and Outcomes: Medical and pharmacy encounter data for the full US Medicare Fee-for-Service population and a claims-based algorithm were used to identify patients with newly diagnosed AdvSM (≥2 medical claims for AdvSM-related diagnoses [ICD-10 C94.3, D47.02, C96.21] or other qualifying mast cell neoplasm codes by subtype) between January 1, 2017, and December 31, 2019. Continuous enrollment in Medicare for 12 months pre- and post-AdvSM diagnosis was required. Demographics, comorbidity profile, and pre-diagnosis healthcare resource utilization were analyzed. A total of 468 patients with AdvSM met the criteria for analysis; most received their index diagnosis from a hematologist/oncologist. The mean (SD) age was 66.8 (13.6) years, 62% were female, 91% were Caucasian, 30% were dually eligible for Medicare/Medicaid (indicating lower socioeconomic status), and 31% qualified for Medicare due to non-age-related factors (e.g., disability). The mean (SD) Charlson Comorbidity Index score was 4.1 (3.2). Comorbidities included hypertension, 65%; malignancies (including mast cell neoplasms, solid tumors, and hematologic cancers), 62%; pulmonary disease, 43%; depression, 32%; anxiety, 29%; diabetes, 29%; asthma, 26%; and osteoporosis, 22%. In the year before AdvSM diagnosis, patients had a mean (SD) of 4.6 (5.1) primary care visits and 19.6 (18.5) physician specialist visits; 22% underwent bone marrow biopsy, 5% KIT D816V mutation testing, and 48% serum tryptase testing. The majority of patients were prescribed anti-mediator drug therapy (67% corticosteroids, 41% proton pump inhibitors, 29% antileukotrienes, 28% montelukast); 20% were prescribed epinephrine injectors for treatment or prevention of anaphylaxis. Medicare patients newly diagnosed with AdvSM had evidence of high rates of comorbid disease, specialist visits, and symptom management regimens prior to confirmed diagnosis. Care should be closely coordinated by specialists to optimize timely AdvSM diagnosis and management.

CLL-217 Patient Characteristics and Time to Next Treatment With Ibrutinib and Anti-CD20 Monotherapy as First-Line Treatment in Patients With Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

While ibrutinib has been established as a preferred first-line (1L) treatment for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL), anti-CD20 monotherapy (rituximab or obinutuzumab) is sometimes prescribed as symptomatic or palliative therapy. To describe and compare patient characteristics and outcomes between ibrutinib and anti-CD20 monotherapy for CLL/SLL patients who initiated a 1L of therapy in community oncology practice. The nationwide electronic health record-derived deidentified database (03/04/2016-09/30/2021) was used to collect medical encounter and prescription data. Patient baseline characteristics before 1L treatment were compared between the two groups. Propensity score-based inverse probability of treatment weighting (IPTW) was used to adjust for baseline differences between groups. Kaplan-Meier (KM) analysis was used to evaluate time to next treatment (TTNT) from 1L initiation. Two subgroup analyses were performed among patients with high-risk cytogenetic markers (del17p, del11q, unmutated IGHV) and those without IGHV testing. Of the 3,226 patients identified, 2,188 (67.8%) received 1L ibrutinib and 1,038 (32.2%) received a 1L anti-CD20 monotherapy. The average age was 71.4 years for ibrutinib users and 72.9 years for anti-CD20 users. Female patients were 39% of those prescribed ibrutinib and 42% of those given anti-CD20. Patients treated with ibrutinib were more likely to have high-risk cytogenetic markers (42.6% vs 27.9%). The median TTNT was not reached in ibrutinib-treated patients and 18.3 months in anti-CD20-treated patients. The hazard ratio was 0.30 (95% CI: 0.27-0.34, p<0.001) in favor of ibrutinib. In the subgroup with high-risk genetic markers, the hazard ratio was 0.26 (0.21-0.33, p<0.001). In the subgroup without IGHV testing, the hazard ratio was 0.30 (0.26-0.36, p<0.001). A substantial number of CLL/SLL patients received 1L treatment with anti-CD20 monotherapy in community oncology practice. The outcomes showed that ibrutinib resulted in a significantly longer duration before starting a second-line treatment compared with anti-CD20 monotherapy. This advantage was consistently demonstrated in patients with high cytogenetic risk features and without IGHV testing.

Estimating Chlamydia and Gonorrhea Burden Among US Army Soldiers From Military Health System Data: Mind the Gap.

Reporting systems are commonly used for chlamydia and gonorrhea surveillance and community burden assessments. Estimates are conservative given high proportions of asymptomatic cases and underreporting. The military's unified health system, which includes laboratory and medical encounter data, could offer insight into surveillance gaps and improve burden analyses. Confirmed chlamydia and gonorrhea cases reported among active component soldiers were merged with laboratory and medical encounter records indicative of infection to identify incident cases during 2015-2019. Case capture across data systems was assessed, and reported case rates were compared with those derived from the enhanced 3-source database. Attributable medical encounters for total cases were extrapolated using average visits for the subset of cases with supporting encounter data. Multivariable generalized linear models were generated to characterize infections. Approximately 83% and 76% of respective chlamydia and gonorrhea cases were identified through reporting, compared with 87% and 67% through laboratory records, and 58% for both through medical encounters. Rates from enhanced 3-source surveillance peaked at 2844 chlamydia and 517 gonorrhea cases per 100,000 person-years in 2019, reflecting 17% and 28% increases in respective rates compared with reported rates. Overall, 3163 cases of chlamydia and/or gonorrhea per 100,000 person-years were detected in 2019, affecting 13,004 soldiers and requiring an estimated 21,690 medical encounters. Soldiers who were younger, female, racial/ethnic minorities, nonmarried, enlisted, less educated, and Southern residents had significantly higher risk. Integration of laboratory and medical encounter data substantially improved burden estimation over reporting alone. Rates generated remain conservative because they only reflect documented cases. Increasing rates support prevention prioritization, particularly among young soldiers.

Pregnancy-associated and pregnancy-related deaths in the United States military, 2003–2014

The Centers for Disease Control and Prevention has reported a steady increase in the US pregnancy-related mortality ratio since national surveillance began in 1987, although trends are partially induced by concurrent improvements in the identification of pregnancy-related deaths. No previous work has evaluated pregnancy-associated and pregnancy-related deaths among active-duty service members, a population with comprehensive health coverage and stable employment. This study aimed to assess trends and variations in pregnancy-associated and pregnancy-related deaths in the US military. Live births to active-duty service members were captured in Department of Defense Birth and Infant Health Research program data from 2003 to 2014. Pregnancy-associated deaths (deaths temporally related to pregnancy from any cause) were identified through 1 year after pregnancy end date using National Death Index Plus data from the Joint Department of Defense and Department of Veterans Affairs Suicide Data Repository. Pregnancy-associated deaths were classified as pregnancy-related (causally related to pregnancy) based on cause-of-death codes in the National Death Index Plus data, administrative medical encounter data, and medical record review. Pregnancy-related deaths were reported including and excluding deaths from suicide and unintentional overdose. Mortality ratios (deaths per 100,000 live births) were reported overall, triennially, and by selected characteristics; the relative contribution of each cause of death to all pregnancy-associated deaths was reported overall and by age, race and ethnicity, and marital status. Timing of death relative to pregnancy end date was assessed by cause of death. A total of 179,252 live births occurred to active-duty service members from 2003 to 2014. Pregnancy-associated and pregnancy-related mortality ratios were 41.3 (95% confidence interval, 32.4-51.8) and 18.4 (95% confidence interval, 12.7-25.9), respectively. Excluding deaths from suicide and unintentional overdose, the pregnancy-related mortality ratio was 11.2 (95% confidence interval, 6.8-17.2). Deaths from suicide and unintentional overdose composed a larger proportion of pregnancy-related deaths over time and accounted for 17.6% of all pregnancy-associated deaths. Deaths from other pregnancy-related causes accounted for a greater share of deaths among older vs younger service members (≥30 years: 41.2%; 18-29 years: 22.8%) and non-Hispanic Black vs White service members (33.3% vs 24.1%). Pregnancy-related deaths, excluding suicide and unintentional overdose, were more likely to occur within 42 days of pregnancy end date; in contrast, deaths from suicide, overdose, assault, and undetermined intent were more likely to occur between 42 days and 1 year after pregnancy. Pregnancy-associated and pregnancy-related deaths varied over time and by age and race and ethnicity. Suicide and overdose are major recent causes of pregnancy-related death among active-duty service members.

Severe Maternal Morbidity among Women in the U. S. Military, 2003-2015.

This study aimed to assess trends and correlates of severe maternal morbidity at delivery among active duty women in the U.S. military, all of whom are guaranteed health care and full employment. Linked military personnel and medical encounter data from the Department of Defense Birth and Infant Health Research program were used to identify a cohort of delivery hospitalizations among active duty military women from January 2003 through August 2015. Cases of severe maternal morbidity were identified by applying 21- and 20-condition algorithms (with and without blood transfusion) developed by the Centers for Disease Control and Prevention. Rates (per 10,000 delivery hospitalizations) were reported overall and by specific condition. Multivariable Poisson regression models estimated associations with demographic, clinical, and military characteristics. Overall, 187,063 hospitalizations for live births were included for analyses. The overall 21- and 20-condition severe maternal morbidity rates were 111.7 (n = 2089) and 37.4 (n = 699) per 10,000 delivery hospitalizations, respectively. The 21-condition rate increased by 184% from 2003 to 2015; the 20-condition rate increased by 40%. Compared with non-Hispanic White women, the adjusted 21-condition rate of severe maternal morbidity was higher for Hispanic (adjusted rate ratio [aRR] = 1.28, 95% confidence interval [CI]: 1.13-1.46), non-Hispanic Black (aRR = 1.34, 95% CI: 1.21-1.49), Asian/Pacific Islander (aRR = 1.35, 95% CI: 1.13-1.61), and American Indian/Alaska Native (aRR = 1.39, 95% CI: 1.06-1.82) women. Rates also varied by age, clinical factors, and deployment history. Active duty U.S. military women experienced an increase in severe maternal morbidity from 2003 to 2015 that followed national trends, despite protective factors such as stable employment and universal health care. Similar to other populations, military women of color were at higher risk for severe maternal morbidity relative to non-Hispanic White military women. Continued surveillance and further investigation into maternal health outcomes are critical for identifying areas of improvement in the Military Health System. · Cesarean delivery and multiple birth were the strongest correlates of severe maternal morbidity in this population.. · Racial disparities persisted across indicators of severe maternal morbidity.. · Rates of disseminated intravascular coagulation were higher than those reported nationally..

Pregnancy and posttraumatic stress disorder: associations with infant outcomes and prenatal care utilization

Background Posttraumatic stress disorder (PTSD) affects 3.6–9.7% of women, and has been associated with adverse outcomes in pregnancy; however, associations with prenatal care (PNC) utilization are not clear. Objective To evaluate associations of PTSD in pregnancy with PNC utilization and adverse infant outcomes in an active-duty military population (a population with universal health insurance). Methods This was a retrospective cohort study of pregnant active-duty service members in Department of Defense Birth and Infant Health Research program data from 2007 to 2014. Administrative medical encounter data were used to define PTSD cases and outcomes of interest. Descriptive statistics and multivariable log-binomial regression compared PNC utilization and adverse infant outcomes (preterm birth, small for gestational age [SGA], major birth defects) among service members with current PTSD (defined as PTSD in the year prior to pregnancy or during pregnancy) to those without current PTSD. Results Of the 103,221 singleton live births identified, 1657 (1.6%) were born to active-duty service members diagnosed with current PTSD. Service members with PTSD were more likely to initiate PNC in the first trimester (93.5% vs. 90.2%) and score adequate plus on the Adequacy of Prenatal Care Utilization Index (63.2% vs. 40.0%) compared to service members without PTSD. PTSD case status was not associated with preterm birth, SGA, or major birth defects, regardless of the adjustment set used (fully adjusted RR 0.96, 95% CI 0.82–1.13; RR 1.08, 95% CI 0.79–1.48; and RR 1.03, 95% CI 0.79–1.34, respectively). Conclusion For pregnant service members with current PTSD, no associations with adverse infant outcomes were noted, and these patients initiated care earlier and had higher PNC utilization scores compared to pregnant service members without current PTSD. Universal health care coverage and utilization of PNC in this population may mitigate adverse pregnancy outcomes observed in civilian populations of patients with PTSD.

Epidemiology and economic burden of bronchiectasis requiring hospitalisation in Singapore.

Background and objectiveLittle is known about the epidemiology and cost of bronchiectasis in Asia. This study describes the disease burden of bronchiectasis in Singapore.MethodsA nationwide administrative dataset was used to identify hospitalisations with bronchiectasis as a diagnosis. Population statistics and medical encounter data were used to estimate the incidence, mortality, prevalence and direct medical costs associated with bronchiectasis requiring hospitalisation.ResultsThere were 420 incident hospitalised bronchiectasis patients in 2017, giving an incidence rate of 10.6 per 100 000. Age-standardised incidence declined on average by 2.7% per year between 2007 and 2017. Incidence rates increased strongly with age in both men and women. Tuberculosis was a secondary diagnosis in 37.5% of incident hospitalisations in 2007, but has declined sharply since then. Patient survival was considerably lower in both men (5-year relative survival ratios (RSR) 0.63, 95% CI 0.59–0.66) and women (5-year RSR 0.75, 95% CI 0.72–0.78). The point prevalence of bronchiectasis was 147.1 per 100 000 in 2017, and increased sharply with age, with >1% of people aged ≥75 years having bronchiectasis. Total first-year costs among incident bronchiectasis patients in 2016 varied widely, with a mean±sd USD 7331±8863. Approximately 10% of the patients admitted in 2016 had total first-year costs of more than USD 14 380.ConclusionBronchiectasis is common and imposes a substantial burden on healthcare costs and survival rates of patients in Singapore.

Incidence of chronic respiratory conditions among oil spill responders: Five years of follow-up in the Deepwater Horizon Oil Spill Coast Guard Cohort study

BackgroundOver ten years after the Deepwater Horizon (DWH) oil spill, our understanding of long term respiratory health risks associated with oil spill response exposures is limited. We conducted a prospective analysis in a cohort of U.S. Coast Guard personnel with universal military healthcare. MethodsFor all active duty cohort members (N = 45,193) in the DWH Oil Spill Coast Guard Cohort Study we obtained medical encounter data from October 01, 2007 to September 30, 2015 (i.e., ~2.5 years pre-spill; ~5.5 years post-spill). We used Cox Proportional Hazards regressions to calculate adjusted hazard ratios (aHR), comparing risks for incident respiratory conditions/symptoms (2010–2015) for: responders vs. non-responders; responders reporting crude oil exposure, any inhalation of crude oil vapors, and being in the vicinity of burning crude oil versus responders without those exposures. We also evaluated self-reported crude oil and oil dispersant exposures, combined. Within-responder comparisons were adjusted for age, sex, and smoking. ResultsWhile elevated aHRs for responder/non-responder comparisons were generally weak, within-responder comparisons showed stronger risks with exposure to crude oil. Notably, for responders reporting exposure to crude oil via inhalation, there were elevated risks for allsinusitis (aHR = 1.48; 95%CI, 1.06–2.06), unspecified chronic sinusitis (aHR = 1.55; 95%CI, 1.08–2.22), chronic obstructive pulmonary disease (COPD) and other allied conditions (aHR = 1.43; 95%CI, 1.00–2.06), and dyspnea and respiratory abnormalities (aHR = 1.29; 95%CI, 1.00–1.67); there was a suggestion of elevated risk for diseases classified as asthma and reactive airway diseases (aHR = 1.18; 95%CI, 0.98–1.41), including the specific condition, asthma (aHR = 1.35; 95%CI, 0.80–2.27), the symptom, shortness of breath (aHR = 1.50; 95%CI, 0.89–2.54), and the overall classification of chronic respiratory conditions (aHR = 1.18; 95%CI, 0.98–1.43). Exposure to both crude oil and dispersant was positively associated with elevated risk for shortness of breath (HR = 2.24; 95%CI, 1.09–4.64). ConclusionsAmong active duty Coast Guard personnel, oil spill clean-up exposures were associated with moderately increased risk for longer term respiratory conditions.

Timing of stress fracture in soldiers during the first 6 career months: a retrospective cohort study.

Stress fractures (SF) are injuries that can result from beginning new or higher volume physical training regimens. The pattern of clinical presentation of SF over time after individuals start a new or more demanding physical training regimen is not well defined in medical literature. Report trends in the clinical presentation of stress fractures over the first six month of soldiers' time in the service. Retrospective Cohort study Setting: This study was conducted using medical encounter and personnel data from U.S. Army soldiers during the first 6 months of their career. U.S. Army soldiers beginning their careers from 2005-2014 (N=701,027). Weekly SF numbers and incidence were calculated overall, as well as by sex, over the first 6 months of military service. SF diagnoses (N=14,155) increased steeply in weeks 3 and 4, with a peak in the overall incidence of SF diagnoses occurring during weeks 5-8. Although clinical incidence of stress fracture generally decreased beyond 8 weeks, incident lower extremity stress fractures continued to present for over 20 weeks. The hazard ratio (HR) for SF among women compared to men was 4.14 (95% CI = [4.01, 4.27]). Across the 6-month study period, women showed over 4 times greater hazard for stress fracture. The results also suggest that health care providers should be particularly vigilant for stress fractures within 3 weeks after the beginning of a new or higher intensity exercise regimen. The incidence of SF may continue to climb for several weeks. Even as stress fracture incidence declines, it should be noted that these injuries may also continue to appear clinically even several months after a change in activity or training.

Incidence of Uterine Bleeding Following Oral Anticoagulant Use in FDA’s Sentinel System

(Abstracted from Am J Obstet Gynecol 2020; doi: 10.1016/j.ajog.2020.11.034) The aim of this study was to improve the understanding among clinicians of uterine bleeding (UB) events requiring intervention among women treated with an oral anticoagulant (OAC) therapy. The authors examined the incidence of UB events in the US Food and Drug Administration's (FDA's) Sentinel System, a database that comprised medical encounter and outpatient pharmacy claims data contributed by 17 public and commercial health insurers and integrated delivery networks.

Association of Combat Experiences With Suicide Attempts Among Active-Duty US Service Members

There is uncertainty about the role that military deployment experiences play in suicide-related outcomes. Most previous research has defined combat experiences broadly, and a limited number of cross-sectional studies have examined the association between specific combat exposure (eg, killing) and suicide-related outcomes. To prospectively examine combat exposures associated with suicide attempts among active-duty US service members while accounting for demographic, military-specific, and mental health factors. This cohort study analyzed data from the Millennium Cohort Study, an ongoing prospective longitudinal study of US service members from all military branches. Participants were enrolled in 4 phases from July 1, 2001, to April 4, 2013, and completed a self-administered survey at enrollment and every 3 to 5 years thereafter. The population for the present study was restricted to active-duty service members from the first 4 enrollment phases who deployed in support of the wars in Iraq and Afghanistan. Questionnaire data were linked with medical encounter data through September 30, 2015. Data analyses were conducted from January 10, 2017, to December 14, 2020. Combat exposure was examined in 3 ways (any combat experience, overall combat severity, and 13 individual combat experiences) using a 13-item self-reported combat measure. Suicide attempts were identified from military electronic hospitalization and ambulatory medical encounter data using the International Classification of Diseases, Ninth Revision codes. Among 57 841 participants, 44 062 were men (76.2%) and 42 095 were non-Hispanic White individuals (72.8%), and the mean (SD) age was 26.9 (5.3) years. During a mean (SD) follow-up period of 5.6 (4.0) years, 235 participants had a suicide attempt (0.4%). Combat exposure, defined broadly, was not associated with suicide attempts in Cox proportional hazards time-to-event regression models after adjustments for demographic and military-specific factors; high combat severity and certain individual combat experiences were associated with an increased risk for suicide attempts. However, these associations were mostly accounted for by mental disorders, especially posttraumatic stress disorder. After adjustment for mental disorders, combat experiences with significant association with suicide attempts included being attacked or ambushed (hazard ratio [HR], 1.55; 95% CI, 1.16-2.06), seeing dead bodies or human remains (HR, 1.34; 95% CI, 1.01-1.78), and being directly responsible for the death of a noncombatant (HR, 1.81; 95% CI, 1.04-3.16). This study suggests that deployed service members who experience high levels of combat or are exposed to certain types of combat experiences (involving unexpected events or those that challenge moral or ethical norms) may be at an increased risk of a suicide attempt, either directly or mediated through a mental disorder.

Characterization of Limited Duty Neuromusculoskeletal Injuries and Return to Duty Times in the U.S. Army During 2017-2018.

Neuromusculoskeletal injuries (MSKI) are the leading cause of medical encounters, lost or limited duty days, medical evacuations, and disability in the U.S. Army. In the U.S. Army, objective MSKI incidence rate metrics can be determined through medical encounter data (M2SKIs) with International Classification of Diseases (ICD) 9 and ICD 10 codes or through documented limited duty profiles (LDPs) documenting time-loss MSKI (TLMSKI). The purpose of the current study was to characterize the population incidence of TLMSKIs among U.S. Army soldiers. This study was approved by the Medical Research and Development Command's Institutional Review Board. This was a retrospective population-level study. The U.S. Army's eProfile system was utilized to characterize all LDPs issued during 2017-2018 and to describe the body regions injured and activities associated with these TLMSKIs. The incidence rate of TLMSKIs was found to be 44 and 40 TLMSKI/100 soldier-years for 2017 and 2018, respectively, which is lower than previously published incidence rates using MSKI receiving medical care. Approximately one quarter of the total active duty Army population in 2017 and 2018 recorded limited duty injuries, where those to the ankle/foot region resulted in the most LDPs and those to the knee resulted in the most lost duty days. The majority of all TLMSKIs were associated with fitness training-related activities. This descriptive study is the first to present the U.S. Army population rates for MSKIs that result in LDPs, representing key time losses when soldiers cannot participate in their military occupational and physical training tasks. This study utilizes the LDP system to calculate limited duty days instead of attempting to estimate this information from other means. The eProfile system is limited in that it combines body regions such as ankle/foot and does not allow isolation of ankle or foot independently. It is recommended that research and training programs target the identification, development, and validation of effective and scaleable strategies to maximize performance without severely reducing combat effectiveness because of training TLMSKIs.

Persistent Respiratory Conditions among Coast Guard Responders to the Deepwater Horizon Oil Spill, Five Years of Follow-up

Background: This year marks the 10th anniversary of the Deepwater Horizon oil spill. To date, little is understood about persistent respiratory conditions associated with oil spill response exposures. We conducted a longitudinal study of incident chronic respiratory conditions in a cohort of U.S. Coast Guard (USCG) responders enrolled in an equal access medical system.Methods: For all active-duty cohort members (N=45,193) we obtained medical encounter data, 10/01/2007-10/1/2015, representing ~2.5 years pre- and ~5.5 years post-spill. We queried incident respiratory conditions classified by International Classification of Diseases, 9th Edition. We used adjusted Cox Proportional Hazards regressions to compare responders to non-responders, responders reporting any crude oil exposure vs. none, and responders reporting any inhalation of crude oil fumes vs. none for earlier (2010-2012) and later (2013-2015) periods. We also evaluated joint effects of self-reported crude oil and oil dispersant exposures. Within-responder comparisons were adjusted for age, sex, and smoking.Results: Responders compared with non-responders were at increased risk in the later period for asthma (HR=1.48), dyspnea (HR=1.23), shortness of breath (HR=1.33), and cough (HR=1.27), in age- and sex-adjusted analyses. Oil exposed responders were at increased risk for asthma in the earlier period (HR=1.60) and for dyspnea (HR=1.52) and shortness of breath (HR=1.88) in the later period. Inhalation exposure was associated with increased risk of many respiratory conditions, including a two-fold elevated risk for shortness of breath in the later period (HR=2.11). Self-reported dispersant exposure further increased this association (HR=2.24). Most HRs were statistically significant.Conclusions: Our study, among a population with equal healthcare access, indicates the potential for crude oil exposures during a spill response to increase the risk for longer-term respiratory conditions.Disclaimer: The contents, views or opinions expressed here are those of the authors and do not reflect official policy or position of USU, the DoD, or the USCG.

Abstract C055: Human papillomavirus vaccination among US military service women

Abstract Human papillomavirus (HPV) is the second most commonly diagnosed sexually transmitted infection in US service women, though the incidence has declined over the last decade, from 364.4 per 10,000 woman-years in 2007 to 90.0 per 10,000 woman-years in 2016. Despite the Department of Defense (DoD) routine vaccination recommendation for eligible service members age 17-26 years and provision of the vaccine free of charge, coverage remains low. During the years 2006-2011, only 22.5% of eligible women initiated the 3-dose series of the quadrivalent HPV vaccine, and it is not known whether receipt of the vaccine varies by demographic, military-specific, or other. We evaluated receipt of the HPV vaccine in a large cohort of active duty service women over the period 2001-2015. The women are part of the Millennium Cohort Study, which comprises over 200,000 current and past service members and is the largest longitudinal cohort of service members in military history. Briefly, participants were first enrolled in 2001 and complete follow-up questionnaires approximately every 3 years. Information on military experiences, lifestyle factors, and physical and mental health are collected at each time point. Additionally, participants can be linked to medical encounter, pharmacy, and national death data. Women who were active duty and age 18-26 years at the time of enrollment were included in the analysis. Medical encounter data and the military's central immunization database were used to identify women who had received at least one dose of the HPV (bivalent, quadrivalent, or nonavalent) vaccine. We used logistic regression to evaluate demographic, military, and health-related factors potentially related to receipt of the vaccine. There were n=14,591 women in our study cohort. Of these, n=4,867 (33.4%) had received at least one dose of the HPV vaccine. Women were less likely to be vaccinated if they were older (odds ratio [OR]=0.85, 95% confidence interval [95% CI]=0.77-0.93 for women age 25-26 years compared to women age 20-24 years), married at baseline (OR=0.79, 95% CI=0.73-0.86 compared to women who were never married), or smokers (OR=0.82, 95% CI=0.76-0.89). Women were more likely to be vaccinated if they were health care specialists (OR=1.43, 95% CI=1.30-1.57 compared to other occupations) or in the Air Force (OR=2.51, 95% CI=2.30-2.75 compared to Army). There were no differences by race, education, or military rank. In the general US population, non-white women are less likely to be vaccinated (41.5% of black, 44.7% of Hispanic or Latino, and 42.3% of Asian women compared to 52.2% in white women). However, in a setting where social determinants of health are in part addressed by equal access to vaccination, no racial differences were observed. Citation Format: Rayna K. Matsuno, Ben Porter, Steven Warner, Deborah B. Bookwalter, Natalie Wells. Human papillomavirus vaccination among US military service women [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C055.

Relationship to Deployment on Sarcoidosis Staging and Severity in Military Personnel.

Ongoing studies are investigating the potential link between deployment to Operation Iraqi Freedom and Operation Enduring Freedom and relationship to increases in pulmonary disease. While increases in certain diseases such as asthma and airway hyperreactivity are well established, data on other chronic pulmonary diseases such as sarcoidosis have not been defined. A retrospective chart review was conducted of all active duty military personnel diagnosed with sarcoidosis from 2005 to 2010. Deployment dates and locations were obtained through the Armed Forces Health Surveillance Branch. Electronic medical records were reviewed to determine the following parameters: dates of diagnosis, temporal relationship of diagnosis and deployment, symptoms (pre- and/or post-deployment), spirometry, diffusing capacity, radiographic staging, and treatment course. Pulmonary sarcoidosis incidence rates were estimated using International Classification of Diseases (ICD-9) coded medical encounter data from the Defense Medical Surveillance System and compared between Army and nonArmy personnel, as well as between ever-deployed and never-deployed personnel. A cohort of 478 Army soldiers was identified with sarcoidosis based on ICD-9 codes and individual review of the medical records. The cohort was 80% male. 38.7% of soldiers with sarcoidosis never deployed. 11.7% were diagnosed prior to deployment, and 50.2% were diagnosed postdeployment. The diagnosis of sarcoidosis was established with a tissue diagnosis in 68% of the deployed cohort. Overall differences in spirometry were not identified. Obstructed spirometry was similar in all deployment groups (never, pre, and post) at 9.2%, 15.8% and 8.7%, respectively. Restrictive patterns based on total lung capacity (<70%) were similar at 9.2%, 12.5%, and 11.0%, respectively. Radiographic staging showed a similar distribution in the populations with the never/pre versus postdeployment groups having Stage 0=2.3 versus 3.5%, Stage I=43.8 versus 41.6%, Stage II=33.1 versus 41.0%, Stage III=15.1 versus 12.1%, and Stage IV=2.2 versus 1.7%, respectively. During 2005-2010, the estimated incidence rate of pulmonary sarcoidosis was low among active duty Army personnel (16.5 cases/100,000 person-years), and no trend in annual rates was observed, p=0.89. Based on overall Department of Defense medical data, estimated pulmonary sarcoidosis rates were lower among ever-deployed personnel, relative to nondeployed personnel. Based on this analysis of Army sarcoidosis patients, there was no difference in the rates of sarcoidosis diagnosis in deployed and nondeployed soldiers. Spirometry values, total lung capacity, and radiographic staging did not show significant differences between deployment groups.