Cumulative from 1st Quarter FY 2002 through 4th Quarter FY Analysis of VA Health Care Utilization among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans VA Office of Public Health and Environmental Hazards February 2010

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

Cumulative from 1st Quarter FY 2002 through 4th Quarter FY 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 3 rd 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 4 th Quarter FY 2009 is 4,898

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

Cumulative from 1st Quarter FY 2002 through 4th Quarter FY 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, 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 Afghanistan 1. 1 As provided by the Armed Force Health Surveillance Center (Personal Communication), 01/20/2010

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

Cumulative from 1st Quarter FY 2002 through 4th Quarter FY VA Health Care Utilization from FY 2002 through 2009 (4 th 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

Cumulative from 1st Quarter FY 2002 through 4th Quarter FY VA Health Care Utilization for FY (4 th 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)

Cumulative from 1st Quarter FY 2002 through 4th Quarter FY 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 (4 th 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).

Cumulative from 1st Quarter FY 2002 through 4th Quarter FY VISN 1VA New England Healthcare System 22, VISN 2VA Healthcare Network Upstate New York 14, VISN 3VA New York/New Jersey Healthcare System 19, VISN 4VA Stars & Stripes Healthcare System 24, VISN 5VA Capital Health Care System 16, VISN 6VA Mid-Atlantic Healthcare System 30, VISN 7VA Atlanta Network 38, VISN 8VA Sunshine Healthcare Network 39, VISN 9VA Mid-South Healthcare Network 29, VISN 10VA Healthcare System of Ohio 15, VISN 11Veterans in Partnership Healthcare Network 23, VISN 12VA Great Lakes Health Care System 27, VISN 15VA Heartland Network 20, VISN 16South Central VA Health Care Network 46, VISN 17VA Heart of Texas Health Care Network 36, VISN 18VA Southwest Healthcare Network 27, VISN 19VA Rocky Mountain Network 22, VISN 20VA Northwest Network 28, VISN 21VA Sierra Pacific Network 24, VISN 22VA Desert Pacific Healthcare Network 43, VISN 23VA Midwest Health Care Network 30, 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.

Cumulative from 1st Quarter FY 2002 through 4th Quarter FY Demographic Characteristics of OEF and OIF Veterans Utilizing VA Health Care % OEF/OIF Veterans (n = 508,152) % OEF/OIF Veterans (n = 508,152) SexUnit Type Male88.1Active Duty53.5 Female11.9Reserve/Guard46.5 Birth Year Cohort*Branch 1980 – Air Force – Army – Marines – Navy – Rank Enlisted91.3 Officer8.7 * 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.

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

Cumulative from 1st Quarter FY 2002 through 4th Quarter FY Diagnosis (Broad ICD-9 Categories)FrequencyPercent Infectious and Parasitic Diseases ( )68, Malignant Neoplasms ( )5, Benign Neoplasms ( )25, Diseases of Endocrine/Nutritional/ Metabolic Systems ( )135, Diseases of Blood and Blood Forming Organs ( )14, Mental Disorders ( )243, Diseases of Nervous System/ Sense Organs ( )202, Diseases of Circulatory System ( )94, Disease of Respiratory System ( )116, Disease of Digestive System ( )172, Diseases of Genitourinary System ( )63, Diseases of Skin ( )93, Diseases of Musculoskeletal System/Connective System ( )265, Symptoms, Signs and Ill Defined Conditions ( )233, Injury/Poisonings ( )130, 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.

Cumulative from 1st Quarter FY 2002 through 4th Quarter FY Frequency of Possible Mental Disorders among OEF/OIF Veterans since Disease Category (ICD code) Total Number of OEF/OIF Veterans 2 PTSD (ICD-9CM ) 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)24,454 Specific Nonpsychotic Mental Disorder due to Organic Brain Damage (310) 15,040 Special Symptoms, Not Elsewhere Classified (307)14,531 Sexual Deviations and Disorders (302)12,382 Persistent Mental Disorders due to Conditions Classified Elsewhere (294) 12,029 1 These are cumulative data since FY 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, 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 ) 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.

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

Cumulative from 1st Quarter FY 2002 through 4th Quarter FY 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 Veterans 1, 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

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

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