Health of the Force

Methods

Last Updated: July 24, 2018
‚ÄčThe 2017 edition of Health of the Force includes several methodological updates, including changes to population selection and rate adjustments. In past issues of Health of the Force, health measures were calculated for a subset of U.S. Army installations where the AC population was greater than 1000 personnel on average. Army reference values in previous reports were specific to U.S. installations, and separate regional reference values were provided for installations located in the European and Pacific regions in the 2016 edition. In the 2017 edition, Army referenced values reflect the entire Army, including installations outside the U.S. When possible, installation values in previous editions of the report were adjusted by sex and age to the population distribution of the respective Army region (i.e., U.S., Europe, or Pacific). These values are now adjusted to the total Army population.


‚ÄčI. Methodological and Data Updates

a. Because adjustment techniques control for potential biases introduced by influential adjustment factors (e.g., age), they are valuable tools for comparing and ranking groups. However, the drawback of reporting adjusted values (as in previous reports) is that they mask an installation's actual values for each measure. The unadjusted values reported in the current edition are useful for installation health assessments because they better reflect the disease burden attributable for each measure within the population and better align with comparable unadjusted values from other readily available military and national data sources. For this reason, unadjusted values have replaced prior adjusted values throughout the report. Age- and sex-adjusted values (not displayed in the report) were calculated for a given measure in order to compare installations and identify the best ranking; these adjusted values were also used to compute the overall installation health index percentile scores.

b. Another noteworthy difference from the prior reports is a change in data sources for certain measures. With the 2017 update, there was a migration to a central data source for clinically driven health measures of diagnosed sleep disorders, and obesity as measured by BMI. The data source migrated from the medical readiness assessment tool (MRAT) to the Defense Medical Surveillance System (DMSS) for sleep metrics and to the Medical Data Repository (MDR) for obesity metrics. While the MDR data migration had little impact on obesity measurements generated from Soldier BMI, the DMSS data migration resulted in the identification of considerably more sleep disorder diagnoses and the introduction of a surveillance artifact.

c. Furthermore, there were institutional changes in the way data providers defined and tracked medical readiness and healthcare delivery data. Specifically, the medical readiness classifications (MRCs) used in prior reports were modified by the executive agency for readiness following a directive from the Secretary of the Army (Army Directive 2016-07) issued in March 2016, and the healthcare delivery metrics (i.e., preventable admissions and HEDIS Composite measures) that were previously attainable through the Command Management System (CMS) are no longer available for inclusion in the report. The new medical readiness measure reflects the updated MRC, and a subset of the individual HEDIS measures that comprised the earlier composite score are now reported for Army healthcare beneficiaries.

d. Due to the methodological and data changes implemented, the reported estimates in this year's report should not be directly compared to those provided in prior reports. When available, trend charts were included that provide historical Army-wide estimates which take these changes into account. The more detailed installation demographic information added to the report also provide further clarity that should aid in data interpretation. Specifics regarding the changes are also provided in the metric methods descriptions that follow.

II. Installation Selection

a. Installation summaries are provided for installations and Joint bases with Army MTFs and a minimum of 1,000 AC Soldiers. Estimates from selected U.S.-based installations and installations outside the U.S. were considered in the reported installation ranges for each evaluated measure. Information pertaining to AC Soldiers from excluded installations was also incorporated in the overall Army estimates.

b. Installation profiles for those installations outside the U.S. were abbreviated and were segregated for the purposes of installation ranking due to inherent differences which may have biased their comparison with U.S.-based installations. For example, Soldiers stationed outside the U.S. are more likely to meet deployment medical standards to qualify for assignment outside the U.S. There are also unique differences in healthcare delivery given that installations located outside the U.S. may be more likely to outsource care. Environmental health indicators were not available for installations outside the U.S.

III. Leading Health Indicators (LHI)

With the exception of medical readiness indicators, which are unique to the military, the LHIs selected were adapted from nationally recognized health indicators routinely tracked by public health authorities such as Healthy People, the Robert Wood Johnson Foundation, and the United Health Foundation. The choice of indicators relevant to the AC Soldier population was based on a modified version of a vetted prioritization scheme developed by the APHC.1,2 The following criteria informed the selection: 1) the importance of the problem to force health and readiness (e.g., prevalence and severity of the condition), 2) the preventability of the problem, 3) the feasibility of the metric, 4) the timeliness/frequency of data captured, and 5) supporting evidence. LHIs and supporting metrics included in the report are described below; the LHIs were included in the Installation Health Index computation and are designated with an asterisk (*) after the metric name.

a. Medical Readiness

1. Medical readiness classification (MRC): MRC data were obtained from the Medical Operational Data System (MODS). Installation assignment was determined by unit identification codes (UICs). Non-deployed AC Soldiers with an MRC of 3 or 4 were identified for the analysis as not medically ready for deployment. Trainees, transients, holdees, and students (TTHS) were excluded. These classifications are defined in Army Directive 2016-07 (Redesign of Personnel Readiness and Medical Deployability). Monthly MRC estimates from June through December 2016 were averaged to approximate the yearly estimate. Monthly variation in MRC was also examined for the Army AC population, revealing stable estimates in aggregate.

2. Dental readiness classification (DRC): DRC, a subset of the MRC, was processed similarly to the MRC. DRC3 represents significant additional dental treatment required (often requiring multiple appointments), which is likely to take 30 days or more. Soldiers overdue for their annual exam are designated DRC4. DRC1 represents no dental treatment needs, and DRC2 equates to minor treatment needs. DRC data were also obtained from MODS, limited to non-deployed, non-TTHS AC Soldiers.

3. Permanent profiles: Profiles (data not shown) are a component of MRC. Profiles are classified in categories 3 and 4 (i.e., P3 and P4), which are considered deployment-limiting permanent profiles.

a. For temporary profiles, MRC is dependent on the duration of the profile. Temporary profiles written for less than or equal to 14 days do not negatively impact a Soldier's medical readiness. Temporary profiles greater than 14 days in duration result in a MRC3. These Soldiers are considered medically nondeployable.,

b. Permanent 2 (or, "P2") profiles do not change a Soldier's MRC. However, a Soldier with a permanent ("P3" or "P4") profile will be classified as MRC3. Many of these Soldiers will remain medically nondeployable pending lengthy additional medical treatment and/or disposition through a MOS Administrative Retention Review and/or the Individual Disability Evaluation System (IDES).

4. Sensory injuries: Because hearing and vision injuries affect profile determination, they are correlated with readiness and provided for additional context. Diagnosed hearing and vision injury rates per 1000 Soldier person-years were assessed using DMSS medical data and established APHC case definitions which utilized relevant ICD9 and ICD10 codes. Processed data were extracted from Public Health 360 (PH360). Detailed methods for injury incidence rate determination are described in the injury section below and are applicable for identification of incident sensory injuries. Additionally, the DOEHRS-HC was used to assess auditory readiness outcomes such as significant threshold shifts (STS). The DOEHRS-HC hearing testing results provide context to the diagnosed hearing injury rates. Installation assignment for clinical diagnoses was based on the ZIP code for the Soldier's assigned unit; DOEHRS-HC data were mapped to an installation based on the location of the clinic performing the auditory testing.

a. Health Outcomes

1. Injury:* The overall incidence of injury and musculoskeletal conditions resulting from injury was evaluated for AC Soldiers and trainees, excluding cadets (for whom complete data were unavailable). Estimates extracted from PH360 included data processed from the DMSS. Installation assignment was determined by the Soldier's unit ZIP code.

New or incident injuries were identified based on ICD9 and ICD10 codes outlined in the Soldier's medical records (direct MTF-based care as well as purchased care covered by TRICARE claims) using published case definitions from the APHC. Only unique medical visits with injury diagnoses codes included in the case definition were counted; follow-up visits less than 60 days apart were excluded. Rates per 1,000 Soldiers were computed based on Soldier person-time; time deployed was excluded to account for missed cases not identified during deployment. Installation estimates were adjusted by sex and age prior to ranking (estimates not shown). The percentage of Soldiers injured during the calendar year was also evaluated for the Army as a whole, including examinations of age and sex differences.

2. Climatic injury: Incidence of climatic injuries (heat and cold weather), a subset of the injury metric, were also provided based on ICD9 and ICD10 code data received from the DMSS. Incidence rules established for injury monitoring were applied with one exception, i.e., estimates included injuries and person-time associated with deployed Soldiers. Climatic injuries