BACKGROUND/RATIONALE:
The growing body of research on Veterans deployed in support of Operations Enduring Freedom, Iraqi Freedom and New Dawn (OEF/OIF/OND) suggests that there are patterns of comorbid conditions that cluster together. A systematic identification of common comorbidity clusters is needed to understand the long-term comorbidity patterns and health care needs of this veteran cohort.

OBJECTIVE(S):
1. Identify comorbidity clusters among OEF/OIF/OND veterans and describe comorbidity trajectories over the first 3 years of VA care.
2. Identify risk factors for trajectories of comorbidity.
3. Compare VA health care utilization for individuals with different comorbidity trajectories.
4. Examine differences in resilient coping, social support and measures of mental health for OEF/OIF/OND VA patients in a random sample stratified to represent comorbidity trajectories.

METHODS:
This prevalent cohort study first identified individuals deployed in support of the wars in Afghanistan and Iraq from the OEF/OIF roster, and combined data from VA national inpatient, outpatient and pharmacy data repositories, survey data, and national VistA Web chart abstraction. We identified specific comorbidities using ICD-9-CM codes each year during the first three years of VA care. We used latent class analysis (LCA) stratified by gender to identify trajectories of comorbidity among individuals first seen in VA care (FY02-09), and examined health care utilization patterns by trajectories. We then identified a random sample of individuals by comorbidity trajectory, oversampling women and individuals in small trajectories, to conduct more comprehensive examination using survey and chart abstraction data. Generalized linear models were used to examine the associations between comorbidity trajectory and resilient coping, social support, and measures of mental health.

FINDINGS/RESULTS:
Aim 1: We first identified comorbidity trajectories using LCA using a derivation and validation cohort. To determine if documentation of mild TBI affected the pattern of comorbidity trajectories, the derivation cohort included those first receiving care in FY07-FY09 due to initiation of TBI screening in FY07; the validation cohort included those who entered VA care in FY02-06. LCA of care-seeking Iraq and Afghanistan Veterans who received 3 or more years of care (FY07-FY11) stratified by gender indicated that a five-trajectory solution best fit the data for women (n=20,216) and a seven-trajectory solution best fit the data for men (n=147,002); a validation cohort of those entering VA care FY02-FY06 revealed the same trajectory patterns. Examination of trajectories revealed that five were similar for men and women: (1) Healthy (~40%), (2) Chronic Disease (hereafter Chronic ~10%), (3) Mental Health (~22%), (4) Pain (~13%), and (5) PCT (TBI, PTSD, and pain; ~15%). The two additional trajectories found for men were (6) Minor Chronic: mostly healthy with significantly higher probabilities of obesity, chronic lung disease, and hearing/vision conditions than the Healthy trajectory but far lower probabilities of these conditions than the Chronic trajectory; and (7) PCT+Chronic based on significantly higher probabilities of obesity, insomnia and hypertension than the PCT-only trajectory.

We further examined patterns of CNS-acting medication use by trajectory as a count at baseline (CNS-Baseline: 0, 1-3; 4+) and CNS-Change (year 3-year 1; reduced, stable, increased), to describe stability within each trajectory. At baseline, individuals in the Healthy and Chronic trajectories were significantly more likely to receive zero CNS medications (88% and 79%, respectively) compared to PCT/PCT+Chronic (36% and 40%, respectively). Those in PCT/PCT+Chronic trajectories were more likely to have 4+ unique CNS medications (19% each) compared to all other trajectories (range 0.3 [Healthy] to 7.5% [Mental Health]). Within all trajectories there was evidence of stability (range: Healthy 76% to PCT/PCT+Chronic 18%), reduced CNS (range: healthy 9.1%, PCT/PCT+Chronic 23% and 21%, respectively), and increased CNS (range healthy 15%, PCT/PCT+Chronic 60% each).

Aim 2: Demographic risk factors for comorbidity trajectories include age and race/ethnicity. Patients in trajectories of chronic disease (Chronic, Minor Chronic, PCT+Chronic) were older overall, regardless of sex. With regard to race/ethnicity, African American men and women were more likely to be included in Chronic, Minor Chronic, and PCT+Chronic trajectories. White men were more likely to be represented in Mental Health and PCT trajectories, and white women were more likely to be represented in the Mental Health trajectory. Those who served in the enlisted forces were more likely to be in Mental Health and PCT/PCT+Chronic Trajectories. Those who served in the National Guard were more likely than expected to be in the PCT+Chronic and Pain trajectories; those who served in the Reserve/National Guard were more likely to be in the Chronic and Healthy trajectories. Those deployed as Active Duty were more likely to be in Minor Chronic, Mental Health and PCT trajectories.

Aim 3: Using VA outpatient (clinic code) and inpatient records, we found that health care utilization in year four of VA care was significantly associated with comorbidity trajectories assessed in the first three years of VA care. Emergency department care, and care in mental health and substance abuse clinics, was significantly less likely in the Healthy, Minor Chronic, Chronic and Pain trajectories than Mental Health and PCT/PCT+Chronic trajectories. Similarly, hospitalization was significantly more likely in Mental Health and PCT/PCT+Chronic trajectories compared to other trajectories. However, on average PCT/PCT+Chronic trajectories also had significantly higher utilization of primary care (Median=2; IQR=3) than the Healthy and Minor Chronic trajectories (Median=1; IQR=2), suggesting overall high healthcare utilization.

Aim 4: Survey respondents had a mean age of 40.7 years (SD = 10.3) in 2014 (3-6 years after data for trajectory identification) and 55% were male (n=1,075). Results of general linear model analyses found no significant interactions with gender, so results are presented by trajectory. Trends across resilient coping, measures of social support and measures of mental health were consistent with those in the Healthy trajectory reporting the most positive scores, and those in the Mental Health, PCT, and PCT+Chronic reporting the least positive scores. Notable findings were related to scores on the health status measure, depression, and pain scores. First, self-rated health in the Healthy Trajectory was only rated as "good." Second, scores on the CES-D for the Healthy Trajectory was 9.3; CES-D scores of 10 or greater are considered "depressed." Finally, the mean pain score of 3.9 for the Healthy trajectory reflects self-reported pain near VA's "clinically significant" cutpoint of 4.

IMPACT:
Far from illustrating a 'healthy warrior effect,' our findings suggest that a significant portion of OEF/OIF/OND Veterans in VA care are experiencing morbidity 5-10 years after entering VA care. These findings suggest a need for additional longitudinal study to monitor well-being over time and longitudinal evaluation of healthcare received by those considered less vulnerable to determine if current structures are meeting their needs.

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External Links for this Project

NIH Reporter

Grant Number: I01HX000329-01A1
Link: https://reporter.nih.gov/project-details/8003060

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PUBLICATIONS:

Journal Articles

1. Finley EP, Bollinger M, Noël PH, Amuan ME, Copeland LA, Pugh JA, Dassori A, Palmer R, Bryan C, Pugh MJ. A national cohort study of the association between the polytrauma clinical triad and suicide-related behavior among US Veterans who served in Iraq and Afghanistan. American journal of public health. 2015 Feb 1; 105(2):380-7. [view]
2. Rohde NN, Baca CB, Van Cott AC, Parko KL, Amuan ME, Pugh MJ. Antiepileptic drug prescribing patterns in Iraq and Afghanistan war veterans with epilepsy. Epilepsy & Behavior : E&B. 2015 May 1; 46:133-9. [view]
3. Pugh MJ, Finley EP, Copeland LA, Wang CP, Noel PH, Amuan ME, Parsons HM, Wells M, Elizondo B, Pugh JA. Complex comorbidity clusters in OEF/OIF veterans: the polytrauma clinical triad and beyond. Medical care. 2014 Feb 1; 52(2):172-81. [view]
4. Bollinger MJ, Schmidt S, Pugh JA, Parsons HM, Copeland LA, Pugh MJ. Erosion of the healthy soldier effect in veterans of US military service in Iraq and Afghanistan. Population Health Metrics [Electronic Resource]. 2015 Mar 18; 13:8. [view]
5. Jaramillo CA, Cooper DB, Wang CP, Tate DF, Eapen BC, York GE, Pugh MJ. Subgroups of US IRAQ and Afghanistan veterans: associations with traumatic brain injury and mental health conditions. Brain imaging and behavior. 2015 Sep 1; 9(3):445-55. [view]
6. Pugh MJ, Orman JA, Jaramillo CA, Salinsky MC, Eapen BC, Towne AR, Amuan ME, Roman G, McNamee SD, Kent TA, McMillan KK, Hamid H, Grafman JH. The prevalence of epilepsy and association with traumatic brain injury in veterans of the Afghanistan and Iraq wars. The Journal of head trauma rehabilitation. 2015 Jan 1; 30(1):29-37. [view]
7. Norman RS, Jaramillo CA, Amuan M, Wells MA, Eapen BC, Pugh MJ. Traumatic brain injury in veterans of the wars in Iraq and Afghanistan: communication disorders stratified by severity of brain injury. Brain injury. 2013 Oct 16; 27(13-14):1623-30. [view]

Conference Presentations

1. Pugh MJ, Baca CB, Rohde N, Van Cott AC. Antiepileptic Drugs Prescribed for Afghanistan/Iraq War Veterans Diagnosed with Epilepsy. Poster session presented at: American Academy of Neurology Annual Meeting; 2014 May 1; Philadelphia, PA. [view]
2. Pugh MJ, Noel PH, Finley EP, Amuan ME, Copeland LA, Pugh JA. Complex Comorbidity Clusters: Beyond the Polytrauma Clinical Triad. Paper presented at: VA HSR&D National Meeting; 2012 Jul 1; National Harbor, MD. [view]
3. Fernandez W, Allred D, Jaramillo C, Eapen B, Copeland LA, Zeber JE, Pugh MJ. ED Utilization Patterns among Veterans of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn. Paper presented at: Association of Military Surgeons of the United States Annual Continuing Education Meeting; 2013 Nov 1; Seattle, WA. [view]
4. Jaramillo CA, Cooper DC, Wang CP, Tate DF, Eapen BC, York G, Pugh MJ. Post-deployment symptom clusters and association with TBI in US Veterans of the Afghanistan and Iraq wars. Paper presented at: International Brain Injury Association Biennial World Congress; 2014 Mar 19; San Francisco, CA. [view]
5. Norman RS, Jaramillo CA, Amuan ME, Eapen BC, Pugh MJ. Stuttering and Traumatic Brain Injury in U.S. Veterans of the Wars in Iraq and Afghanistan. Paper presented at: International Brain Injury Association Biennial World Congress; 2014 Mar 19; San Francisco, CA. [view]
6. Pugh MJ, Jaramillo C, Eapen B, Roman G, Kent T. The Nexus of TBI and Dementia. Poster session presented at: American Academy of Neurology Annual Meeting; 2013 Mar 1; San Diego, CA. [view]
7. Pugh MJ, Amuan ME. The Nexus of TBI and Epilepsy in Veterans From Afghanistan and Iraq Wars. Paper presented at: American Academy of Neurology Annual Meeting; 2012 Apr 22; New Orleans, LA. [view]
8. Pugh MJ, Amuan ME. The Nexus of TBI and Epilepsy in Veterans From Afghanistan and Iraq Wars. Paper presented at: VA HSR&D National Meeting; 2012 Jul 1; National Harbor, MD. [view]
9. Pugh MJ, Jaramillo C, Eapen B, Roman G, Kent T. The Nexus of TBI and Mild Cognitive Impairment. Poster session presented at: American Academy of Neurology Annual Meeting; 2013 Mar 1; San Diego, CA. [view]
10. Pugh MJ, Orman JA, Jaramillo CA, Eapen BC, Grafman JH. The prevalence of epilepsy and association with traumatic brain injury in veterans of the Afghanistan and Iraq wars. Paper presented at: International Brain Injury Association Biennial World Congress; 2014 Mar 19; San Francisco, CA. [view]
11. Jaramillo CA, Eapen BC, McGeary C, McGeary DD, Pugh MJ. Traumatic brain injury and common comorbidities associated with prevalence and persistent post-deployment headaches among US Veterans of Afghanistan and Iraq wars. Paper presented at: International Brain Injury Association Biennial World Congress; 2014 Mar 19; San Francisco, CA. [view]

DRA: Acute and Combat-Related Injury, Brain and Spinal Cord Injuries and Disorders, Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Diagnosis, Prognosis
Keywords: none
MeSH Terms: none