US ARMY Public Health Command

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1 US ARMY Public Health Command Morbidity Burdens, Army Non-Active Duty Beneficiaries, 2012 Photo graphic using models Approved for public release; distribution unlimited.

2 ii TABLE OF CONTENTS BACKGROUND...1 METHODS...1 RESULTS...1 LIMITATIONS...5 CONCLUSIONS...5 REFERENCES...6 Appendix A: Morbidity Burden Detail, Army Non-AD Beneficiaries, CY Appendix B: Morbidity Burden Summaries by Age, Army Non-AD Beneficiaries, CY Appendix C: Morbidity Burden, Army Non-AD Beneficiaries, European Regional Medical Command (ERMC), CY Appendix D: Morbidity Burden, Army Non-AD Beneficiaries, Pacific Regional Medical Command (PRMC), CY Appendix E: Morbidity Burden, Army Non-AD Beneficiaries, North Regional Medical Command (NRMC), CY Appendix F: Morbidity Burden, Army Non-AD Beneficiaries, Southern Regional Medical Command (SRMC), CY Appendix G: Morbidity Burden, Army Non-AD Beneficiaries, Western Regional Medical Command (WRMC), CY

3 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 1 BACKGROUND Morbidity burden estimates provide a means of assessing the relative magnitude of health outcomes among populations of interest. Morbidity burden is tracked annually for DoD active duty (AD) Servicemembers by the Armed Forces Health Surveillance Center (AFHSC). The (AIPH) has produced similar summaries for the Army AD population since 2005, 1 and in 2013 as part of larger initiative to assess selected indicators of health within Army communities. 2 However, such summaries do not exist for Army or DoD non-ad beneficiaries. This summary is an attempt to begin this process. It provides baseline health outcome information for this understudied population, and may serve to guide prevention campaigns such as the Army s Performance Triad. This campaign aims to improve sleep, activity, and nutrition, all of which are cornerstones for improved health outcomes and reduced morbidity burden. Lessons learned will also prove useful for expansion of ongoing AIPH surveillance efforts to include this population. METHODS Data summarized are limited to non-ad Army beneficiaries (e.g., dependents, retirees and non-activated Guard and Reserve members). Burden estimates associated with major diagnostic categories for calendar year (CY) 2012 are represented in terms of medical encounters, hospital bed days and affected individuals. Both direct care received from military treatment facilities (MTFs) and purchased care medical claims submitted from civilian providers are included. Morbidity burden data were extracted from the Defense Medical Surveillance System (DMSS) managed by the AFHSC using established data management and analysis procedures summarized in published reports; this includes adaptation of diagnostic groups developed by the Global Burden of Disease Study to classify the primary or first-listed diagnosis code in the patient s medical records. 3 The Defense Enrollment and Eligibility Reporting System (DEERS) table within the MHS Mart (M2) was used to generate population estimates of eligible Army non-ad beneficiaries contributing to the morbidity burden. Although the summaries in this report represent the Army as a whole, DMSS and DEERS data were extracted with sex, age and geographic strata to allow future assessments by population groups. RESULTS A total of 31,647,256 medical encounters and 225,861 hospital bed days among 3,248,553 Army non-ad beneficiaries eligible for care were documented in CY Non-descript signs/symptoms diagnoses (e.g., cough, sore throat, chest pain) accounted for the majority of the morbidity burden associated with medical encounters (3,904,989 or 12%), followed by musculoskeletal conditions and injuries with 3,517,945 (11%) and 3,058,528 (10%)

4 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 2 encounters, respectively. Signs/symptoms also accounted for the majority of eligible non-ad beneficiaries affected (1,265,399 or 39%), followed by injuries (27%), respiratory infections (26%), sense organ disease (25%), musculoskeletal conditions (23%), and cardiovascular disease (21%). Maternal conditions accounted for the majority (32%) of documented bed days, followed by digestive disease (10%) and cardiovascular disease (8%) (Figure 1). Medical conditions within each burden of disease category were also reviewed to determine the predominant diagnoses contributing to each (Appendix A). Unspecified or other medical conditions (e.g., musculoskeletal, signs/symptoms, cardiovascular, skin disease), and more specific conditions such as respiratory infections (upper or lower), musculoskeletal conditions (back), essential hypertension and signs/symptoms (respiratory/chest) were in the top 10 conditions identified for one or more morbidity burden criteria (i.e., encounters, individuals affected or associated bed days). Maternal deliveries and pregnancy complications ranked highest in terms of associated bed days. Other diagnoses which rounded out the top 10 included mental disorders (other), diabetes mellitus, signs/symptoms (abdomen/pelvis), sense organ disease (other), digestive disease (other), injury complications, genitourinary disease (other), and infectious/parasitic disease (other) (Table 1). Table 1. Top 10 Medical Conditions by Burden of Disease Criteria, Army Non-AD Beneficiaries, CY Signs/symptoms (other) 1. Signs/symptoms (other) 1. Maternal (delivery) 2. Musculoskeletal (other) 2. Upper respiratory infection 2. Pregnancy complications 3. Musculoskeletal ( back) 3. Musculoskeletal (other) 3. Digestive disease (other) 4. Cardiovascular (other) 4. Skin disease (other) 4. Cardiovascular (other) 5. Mental disorders (other) 5. Signs/symptoms (resp/chest) 5. Lower respiratory infections 6. Diabetes mellitus 6. Essential hypertension 6. Injury complications 7. Skin disease (other) 7. Sense organ disease (other) 7. Signs/symptoms (resp/chest) 8. Signs/symptoms (resp/chest) 8. Signs/symptoms (abdomen/pelvis) 8. Signs/symptoms (other) 9. Essential hypertension 9. Skin disease (other) 9. Genitourinary disease (other) 10. Upper respiratory infections 10. Musculoskeletal (back) 10. Infectious/parasitic (other) Burden estimates varied by age, with individuals 45 years and older accounting for the majority of medical encounters for most major diagnostic categories with the exception of maternal/perinatal conditions and congenital anomalies. Healthcare utilization or burden was more evenly distributed across age categories for mental disorders, respiratory infections, and oral conditions (Figure 2). Additional burden summaries, similar to those provided in Figure 1, are provided by age category in Appendix B. Summaries by regional medical command (RMC) are provided in Appendices C-G.

5 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 3 Figure 1. Medical Encounters a, Individuals Affected b, and Hospital Bed Days c by Burden of Disease Category, Army Non-AD Beneficiaries CY2012 Medical encounters/individuals affected 4,500,000 4,000,000 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000, , ,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 Bed days Burden of Disease Categories a Data provided by AFHSC; major categories and conditions were adapted from the Global Burden of Disease Study. AFHSC burden categories are currently under revision. b Medical encounters: total hospitalizations and ambulatory visits for the condition with no more than one encounter per individual per day per condition. c Individuals with at least one hospitalization or ambulatory visit for the condition. * Bed day estimates exclude bed days at civilian treatment facilities.

6 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 4 Figure 2. Medical Encounters by Burden of Disease Category and Age Group, Army Non-AD Beneficiaries, CY2012 %45+ yrs %20-44 yrs %<20 yrs Medical Encounters %Attributable by Age ,500,000 4,000,000 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000, ,000 0 Medical encounters (count) Burden of Disease Categories

7 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 5 LIMITATIONS Several noteworthy limitations should be taken into consideration for future burden approximations among non-ad beneficiaries. First, the DMSS extract did not capture hospital bed days from civilian facilities. Because a large proportion of non-ad beneficiary care occurs in these facilities, reported bed day estimates are lower than the actual values. This is evidenced by the lower bed day estimate among this population as compared to their AD counterparts, despite having nearly eight-fold their medical encounters 1. Second, because the DMSS lacks beneficiary residence, enrollment, and eligibility information captured in DEERS, regional burden estimation is limited. The lowest level geographic region available for beneficiaries seen outside of MTFs is the state and country where medical encounter occurred; therefore, it was not possible to generate desired installation level summaries for this population. Approximately 10% of the morbidity burden could not be assigned to a known region using the state as a proxy. M2 or the Medical Data Repository (MDR) which populates M2 would be a better source for future morbidity burden estimates given that they house both medical records and DEERS personnel information. Third, the data presented are based primarily on review of centralized medical records for documented ICD9 diagnosis codes. This type of passive surveillance is limited by variations in coding practices across MTFs and the possibility of misclassification due to incorrect ICD9 entries or lack of ICD9 documentation for certain conditions. Differences in coding practices between civilian and military providers may also occur. Additionally, certain conditions which are coded based on pain or symptoms may not reflect the cause of interest (e.g., lumbago diagnoses due to injury and cough diagnoses due to respiratory infections). Finally, incomplete data capture is likely given that many health outcomes of interest go undetected or undocumented by the Military Health System (MHS). This may be due to beneficiaries not seeking care or seeking care outside of the MHS without Tricare reimbursement. Likewise, health outcomes are not always documented in the medical records using definitive ICD9 codes (e.g., medical screening). This is particularly true for infectious diseases, for which laboratory or reportable medical event databases may provide more optimal case capture. CONCLUSIONS The morbidity burdens described establish baseline healthcare utilization estimates for a comprehensive set of health outcomes among the Army non-ad population. Ideally, these summaries could be delineated by beneficiary type and installation to better guide local prevention efforts. The information summarized in this report is the first step toward the desired end state, which will entail integration of non-ad beneficiary data into an automated

8 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 6 platform from which community or installation-level health status reports can be generated. The analysis uncovered important data limitations and potential solutions which should be addressed in future updates. REFERENCES 1. Dada-Laseinde E, M Canham-Chervak, N Clemmons, and BH Jones. U.S. Army Annual Injury Epidemiology Report 2007 (Report No. 12-HF-0APLa -08). U.S. Army Center for Health Promotion and Preventive Medicine: Aberdeen Proving Ground, MD Army Community Health Status, USAPHC Report, limited governmental distribution. Aug Armed Forces Health Surveillance Center. Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, U.S. Armed Forces, MSMR, 19(4):4-9, April 2012.

9 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 7 Appendix A: Morbidity Burden Detail, Army Non-AD Beneficiaries, CY2012 Medical encounters Individuals affected a Bed days Blood disorders 352, ,097 2,937 All other blood disorders 88, , Other non-deficiency anemias 150, , Iron-deficiency anemia 64, , Hereditary anemias 10, , Other deficiency anemias 37, , Cardiovascular disease 2,781, ,836 18,974 All other cardiovascular diseases 1,211, , ,753 4 Ischemic heart disease 425, , , Cerebrovascular disease 257, , , Essential hypertension 872, , Inflammatory 3, , Rheumatic heart disease 11, , Congenital anomalies 170,516 63, All other congenital anomalies 136, , Congenital heart disease 25, , Other circulatory anomalies 8, , Diabetes mellitus 911, ,898 2,264 Diabetes mellitus 911, , , Digestive diseases 982, ,397 22,682 All other digestive diseases 664, , ,643 3 Appendicitis 9, , , Esophagus disease 179, , Other gastroenteritis and colitis 70, , Peptic ulcer disease 11, , Cirrhosis of the liver 29, , Inguinal hernia 18, , Endocrine disorders 363, , Other thyroid disorders 87, , All other endocrine disorders 118, , Hypothyroidism 158, , Genitourinary diseases 1,939, ,385 11,374 All other genitourinary diseases 737, , ,091 9 Nephritis and nephrosis 733, , , Menstrual disorders 118, , , Kidney stones 71, , Female genital pain 101, ,

10 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 8 Medical encounters Individuals affected a Bed days Benign prostatic hypertrophy 73, , Other breast disorders 105, , Headache 261, , Headache 261, , Infectious/parasitic diseases 711, ,205 6,607 All other infectious and parasitic diseases 506, , , Diarrheal diseases 39, , , STDs 73, , Unspecified viral infection 68, , Tuberculosis 1, Hepatitis B and C 14, , Bacterial meningitis Intestinal nematode infection 2, , Chlamydia 3, , Tropical cluster Malaria Injury and poisoning 3,058, ,569 17,052 Other complications NOS 149, , ,960 6 Leg 343, , , Environmental 74, , , Back and abdomen 146, , , Arm and shoulder 747, , , Poisoning, drugs 19, , , Head and neck 215, , Foot and ankle 378, , Other injury from external causes 62, , Knee 487, , Hand and wrist 216, , Unspecified injury 177, , Poisoning, nondrug 11, , All other injury 28, , Malignant neoplasms 922, ,177 6,195 All other malignant neoplasms 109, , , Trachea, bronchus and lung 102, , Colon and rectum 56, , Breast 153, , Lymphoma and multiple myeloma 78, , Thyroid 12, , Pancreas 16, ,

11 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 9 Medical encounters Individuals affected a Bed days Prostate 122, , Bladder 30, , Leukemia 36, , Stomach 8, , Mouth and oropharynx 22, , Ovary 14, , Brain 13, , Liver 7, , Corpus uteri 10, , Cervix uteri 4, Esophagus 11, Melanoma and other skin 109, , Testicular Maternal 543, ,331 73,059 Delivery 185, , ,674 1 Pregnancy complications 325, , ,694 2 Ectopic/miscarriage/abortion 23, , Puerperium complications 8, , All other maternal disorders Mental disorders 2,809, ,262 4,042 Mood 805, , , Substance abuse 70, , , All other mental disorders 1,099, , Psychotic 66, , Adjustment 361, , Anxiety 375, , Personality 7, , Somatoform 7, , Tobacco dependence 15, , Metabolic/immunologic disorders 505, ,893 2,341 Other metabolic disorders 137, , , Immunity disorders 13, , Lipoid metabolism disorders 353, , Musculoskeletal conditions 3,517, ,948 7,321 All other musculoskeletal diseases 1,629, , , Other knee disorders 258, , , Other back problems 1,310, , , Osteoarthritis 187, , Rheumatoid arthritis 83, ,

12 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 10 Medical encounters Individuals affected a Bed days Other shoulder disorders 48, , Neurologic conditions 965, ,498 2,706 All other neurologic conditions 370, , , Organic sleep disorders 448, , Epilepsy 49, , Multiple sclerosis 27, , Parkinson s disease 38, , Other mononeuritis - upper and lower limbs 31, , Nutritional disorders 164,061 77,076 3,350 Overweight, obesity 58, , , Protein-energy malnutrition 11, , All other nutritional disorders 94, , Oral conditions 76,764 54, All other oral conditions 66, , Dental caries 8, , Periodontal disease 2, , Other neoplasms 431, ,108 2,880 All other neoplasms 321, , , Uterine leiomyoma 21, , , Lipoma 10, , Benign skin neoplasm 77, , Perinatal anomalies 158,413 38,567 2,737 All other perinatal anomalies 68, , , Birth asphyxia and birth trauma 40, , Low birth weight 49, , Respiratory disease 1,921, ,531 8,253 All other respiratory diseases 455, , , Chronic obstructive pulmonary disease 549, , , Asthma 254, , , Chronic sinusitis 104, , Allergic rhinitis 557, , Respiratory infections 1,534, ,868 8,973 Lower respiratory infections 406, , ,177 5 Upper respiratory infections 815, , Otitis media 312, , Sense organ disease 1,484, , All other sense organ diseases 736, , Cataracts 238, , Hearing disorders 92, ,

13 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 11 Medical encounters Individuals affected a Bed days Refraction/accommodation 216, , Glaucoma 200, , Signs/symptoms 3,904,989 1,265,399 14,488 Respiratory and chest 891, , ,333 7 All other signs and symptoms 2,302, , ,155 8 Abdomen and pelvis 710, , , Skin disorders 1,175, ,236 4,098 All other skin diseases 898, , , Contact dermatitis 157, , Sebaceous gland diseases 119, , Totals 31,647,256 NA b 225,861 a Numbers of individuals affected within each diagnosis sub-category may not add to the total number affected for each major category given that individuals may have more than one of the conditions listed within each major category. b Numbers of individuals affected for each major diagnostic category cannot be added to generate a total number of affected individuals due to potential comorbidities; the number of non-ad beneficiaries eligible for healthcare coverage through Tricare = 3,248,553.

14 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 12 Appendix B: Morbidity Burden Summaries by Age, Army Non-AD Beneficiaries, CY2012 Figure B1. Medical Encounters a, Individuals Affected b, and Hospital Bed Days c by Burden of Disease Category, Army Non-AD Beneficiaries Under 20 years, CY2012 Medical encounters/individuals affected 1,600,000 1,400,000 1,200,000 1,000, , , , , ,500 4,000 3,500 3,000 2,500 2,000 1,500 1, Bed days Burden of Disease Categories a Data provided by AFHSC; major categories and conditions were adapted from the Global Burden of Disease Study. b Medical encounters: total hospitalizations and ambulatory visits for the condition with no more than one encounter per individual per day per condition. c Individuals with at least one hospitalization or ambulatory visit for the condition. * Bed day estimates exclude bed days at civilian treatment facilities.

15 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 13 Figure B2. Medical Encounters a, Individuals Affected b, and Hospital Bed Days c by Burden of Disease Category, Army Non-AD Beneficiaries years, CY2012 Medical encounters/individuals affected 800, , , , , , , , ,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 Bed days Burden of Disease Categories a Data provided by AFHSC; major categories and conditions were adapted from the Global Burden of Disease Study. b Medical encounters: total hospitalizations and ambulatory visits for the condition with no more than one encounter per individual per day per condition. c Individuals with at least one hospitalization or ambulatory visit for the condition. * Bed day estimates exclude bed days at civilian treatment facilities.

16 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 14 Figure B3. Medical Encounters a, Individuals Affected b, and Hospital Bed Days c by Burden of Disease Category, Army Non-AD Beneficiaries 45+ years, CY2012 Medical encounters/individuals affected 3,000,000 2,500,000 2,000,000 1,500,000 1,000, , ,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Bed Days Burden of Disease Categories a Data provided by AFHSC; major categories and conditions were adapted from the Global Burden of Disease Study. b Medical encounters: total hospitalizations and ambulatory visits for the condition with no more than one encounter per individual per day per condition. c Individuals with at least one hospitalization or ambulatory visit for the condition. * Bed day estimates exclude bed days at civilian treatment facilities.

17 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 15 Appendix C: Morbidity Burden, Army Non-AD Beneficiaries, European Regional Medical Command (ERMC), CY2012 Figure C-1. Medical Encounters a, Individuals Affected b, and Hospital Bed Days c by Burden of Disease Category, Army Non-AD Beneficiaries, ERMC, CY2012 Medical encounters/individuals affected 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5, ,600 1,400 1,200 1, Bed days Burden of Disease Categories a Data provided by AFHSC; major categories and conditions were adapted from the Global Burden of Disease Study. b Medical encounters: total hospitalizations and ambulatory visits for the condition with no more than one encounter per individual per day per condition. c Individuals with at least one hospitalization or ambulatory visit for the condition. * Bed day estimates exclude bed days at civilian treatment facilities.

18 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 16 Figure C-2. %Medical Encounters by Burden of Disease Category, Army Non-AD Beneficiaries, CY2012 ERMC Army Percent Burden of Disease Categories

19 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 17 Table C-1. Top 10 Medical Conditions by Burden of Disease Criteria, ERMC Non-AD Beneficiaries, CY Signs/symptoms - other 1. Upper respiratory infections 1. Maternal - delivery 2. Upper respiratory infections 2. Signs/symptoms - other 2. Pregnancy complications 3. Mental disorders - other 3. Skin disease - other 3. Injury complications 4. Mood disorders 4. Sense organ disease - other 4. Lower respiratory infections 5. Skin disease - other 5. Sense organ - refraction/accommodation 5. Cardiovascular - other 6. Anxiety 6. Infectious/parasitic - other 6. Digestive disease - other 7. Sense organ disease - other 7. Musculoskeletal - other 7. Diabetes mellitus 8. Adjustment reaction 8. Signs/symptoms - abdomen/pelvis 8. Cerebrovascular disease 9. Infectious/parasitic - other 9. Mental disorders - other 9. Signs/symptoms - other 10. Musculoskeletal - other 10. Genito-urinary - other 10. Skin disease - other

20 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 18 Table C-2. Morbidity Burden Detail, Army Non-AD Beneficiaries, ERMC, CY2012 Blood disorders 1, Iron-deficiency anemia Other non-deficiency anemias All other blood disorders Hereditary anemias Other deficiency anemias Cardiovascular disease 6,744 3, Essential hypertension 3, , All other cardiovascular diseases 2, , Ischemic heart disease Cerebrovascular disease Rheumatic heart disease Inflammatory Congenital anomalies 1, All other congenital anomalies Congenital heart disease Other circulatory anomalies Diabetes mellitus 2,950 1, Diabetes mellitus 2, , Digestive diseases 5,421 3, All other digestive diseases 2, , Other gastroenteritis and colitis 1, , Esophagus disease 1, Inguinal hernia Appendicitis Cirrhosis of the liver Peptic ulcer disease Endocrine disorders 2,398 1, Hypothyroidism 1, Other thyroid disorders All other endocrine disorders Genitourinary diseases 8,636 5, All other genito-urinary diseases 4, , Menstrual disorders 1, , Female genital pain 1, Other breast disorders 1, Nephritis and nephrosis Kidney stones Benign prostatic hypertrophy

21 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 19 Headache 2,901 1, Headache 2, , Infect/parasitic diseases 9,459 6, Other infectious/parasitic diseases 6, , Unspecified viral infection 1, , STDs Diarrheal diseases Intestinal nematode infection Chlamydia Hepatitis B and C Tuberculosis Malaria Tropical cluster Bacterial meningitis Injury and poisoning 18,226 10, Arm and shoulder 3, , Foot and ankle 2, , Knee 2, , Hand and wrist 1, , Head and neck 1, , Unspecified injury 1, , Leg 1, Back and abdomen Other complications NOS Environmental Other injury from external causes All other injury Poisoning, drugs Poisoning, nondrug Malignant neoplasms Lymphoma and multiple myeloma Prostate cancer Melanoma and other skin cancers All other malignant neoplasms Breast Colon and rectum Thyroid Leukemia Trachea, bronchus and lung Bladder

22 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 20 Stomach Mouth and oropharynx Ovary Corpus uteri Esophagus Cervix uteri Pancreas Brain Testicular Liver Maternal 6,031 1,702 1,464 Pregnancy complications 4, , Delivery 1, ,096 1 Ectopic/miscarriage/abortion Puerperium complications Mental disorders 35,266 8, All other mental disorders 11, , Mood 8, , Anxiety 6, , Adjustment 6, , Substance abuse Tobacco dependence Psychotic Personality Somatoform Metabolic/immunologic disorders 1,734 1, Lipoid metabolism disorders 1, , Other metabolic disorders Immunity disorders Musculoskeletal conditions 13,219 6, All other musculoskeletal diseases 6, , Other back problems 5, , Other knee disorders Osteoarthritis Rheumatoid arthritis Other shoulder disorders Neurologic conditions 2,330 1, All other neurologic conditions 1, Epilepsy Organic sleep disorders

23 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 21 Multiple sclerosis Other mononeuritis - upper and lower limbs Parkinson disease Nutritional disorders 1, All other nutritional disorders Overweight, obesity Protein-energy malnutrition Oral conditions All other oral conditions Dental caries Periodontal disease Other neoplasms 2,022 1, All other neoplasms 1, Benign skin neoplasm Uterine leiomyoma Lipoma Perinatal anomalies All other perinatal anomalies Low birth weight Birth asphyxia and birth trauma Respiratory disease 9,740 7, Allergic rhinitis 2, , Asthma 2, , Chronic sinusitis 1, , All other respiratory diseases 1, , Chronic obstructive pulmonary disease 1, Respiratory infections 18,564 12, Upper respiratory infections 12, , Otitis media 4, , Lower respiratory infections 2, , Sense organ disease 13,719 10, All other sense organ diseases 6, , Refraction/accommodation 5, , Hearing disorders Glaucoma Cataracts Signs/symptoms 21,374 13, All other signs and symptoms 13, , Abdomen and pelvis 4, ,

24 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 22 Respiratory and chest 3, , Skin disorders 13,141 8, All other skin diseases 8, , Contact dermatitis 2, , Sebaceous gland diseases 1, , Totals 200,243 NA 4,740 a Numbers of individuals affected within each diagnosis sub-category may not add to the total number affected for each major category given that individuals may have more than one of the conditions listed within each major category. b Numbers of individuals affected for each major diagnostic category can t be added to generate a total number of affected individuals due to potential comorbidities; approximately 68,000 non-ad beneficiaries were enrolled at an ERMC facility or known to reside in ERMC in 2012,

25 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 23 Appendix D: Morbidity Burden, Army Non-AD Beneficiaries, Pacific Regional Medical Command (PRMC), CY2012 Figure D-1. Medical Encounters a, Individuals Affected b, and Hospital Bed Days c by Burden of Disease Category, Army Non-AD Beneficiaries, PRMC, CY2012 Medical encounters/individuals affected Bed days Burden of Disease Category a Data provided by AFHSC; major categories and conditions were adapted from the Global Burden of Disease Study. b Medical encounters: total hospitalizations and ambulatory visits for the condition with no more than one encounter per individual per day per condition. c Individuals with at least one hospitalization or ambulatory visit for the condition. * Bed day estimates exclude bed days at civilian treatment facilities.

26 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 24 Figure D-2. %Medical Encounters by Burden of Disease Category, Army Non-AD Beneficiaries, CY PRMC Army Percent Burden of Disease Categories

27 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 25 Table D-1. Top 10 Medical Conditions by Burden of Disease Criteria, PRMC Non-AD Beneficiaries, CY Mental disorders - other 1. Signs/symptoms - other 1. Maternal - delivery 2. Signs/symptoms - other 2. Upper respiratory infections 2. Pregnancy complications 3. Upper respiratory infections 3. Sense organ disease - other 3. Digestive disease - other 4. Musculoskeletal - other 4. Skin disease - other 4. Respiratory disease - other 5. Skin disease - other 5. Musculoskeletal - other 5. Infectious/parasitic - other 6. Sense organ disease - other 6. Signs/symptoms - abdomen/pelvis 6. Mood disorders 7. Musculoskeletal - back 7. Signs/symptoms - respiratory/chest 7. Cardiovascular - other 8. Pregnancy complication 8. Genito-urinary - other 8. Lower respiratory infections 9. Mood disorders 9. Sense organ disease - refraction/accommodation 9. Metabolic disorders - other 10. Genito-urinary disease - other 10. Infectious/parasitic - other 10. Signs/symptoms - other

28 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 26 Table D-2. Morbidity Burden Detail, PRMC Non-AD Beneficiaries, CY2012 Medical encounters Individuals affected Bed days Blood disorders 2,752 1, Other non-deficiency anemias 1, All other blood disorders Iron-deficiency anemia Hereditary anemias Other deficiency anemias Cardiovascular disease 21,033 7,525 1,096 All other cardiovascular diseases 8, , Essential hypertension 8, , Ischemic heart disease 2, Cerebrovascular disease 1, Rheumatic heart disease Inflammatory Congenital anomalies 3,193 1, All other congenital anomalies 2, , Congenital heart disease Other circulatory anomalies Diabetes mellitus 8,940 3, Diabetes mellitus 8, , Digestive disease 13,006 6,903 1,690 All other digestive diseases 8, , ,304 3 Esophagus disease 2, , Other gastroenteritis and colitis 1, , Cirrhosis of the liver Inguinal hernia Appendicitis Peptic ulcer disease Endocrine disorders 3,566 1, Hypothyroidism 1, Other thyroid disorders 1, All other endocrine disorders 1, Genito-urinary disease 24,468 10, All other genito-urinary diseases 10, , Nephritis and nephrosis 5, Menstrual disorders 3, , Female genital pain 2, , Other breast disorders 1, , Kidney stones

29 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 27 Medical encounters Individuals affected Bed days Benign prostatic hypertrophy Headache 4,963 2, Headache 4, , Infectious and parasitic disease 13,403 9, All other infectious and parasitic 8,037 diseases 20 5, Unspecified viral infection 2, , STDs 1, , Diarrheal diseases Hepatitis B and C Intestinal nematode infection Chlamydia Tuberculosis Tropical cluster Malaria Bacterial meningitis Injury and poisoning 40,462 18,179 1,471 Arm and shoulder 8, , Knee 6, , Foot and ankle 5, , Head and neck 4, , Hand and wrist 3, , Leg 3, , Unspecified injury 3, , Back and abdomen 2, , Other complications NOS 1, Environmental 1, Other injury from external causes All other injury Poisoning, drugs Poisoning, nondrug Malignant neoplasms 6,636 1, Breast 1, All other malignant neoplasms 1, Prostate Melanoma and other skin Colon and rectum Lymphoma and multiple myeloma Trachea, bronchus and lung Leukemia

30 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 28 Medical encounters Individuals affected Bed days Thyroid Ovary Liver Bladder Brain Corpus uteri Cervix uteri Mouth and oropharynx Stomach Pancreas Esophagus Testicular Maternal 19,553 4,462 6,194 Pregnancy complications 12, , ,213 2 Delivery 5, , ,624 1 Ectopic/miscarriage/abortion Puerperium complications All other maternal disorders Mental disorders 69,309 10,238 1,099 All other mental disorders 38, , Mood 11, , Anxiety 8, , Adjustment 8, , Substance abuse 1, Tobacco dependence Psychotic Somatoform Personality Metabolic and immunity disorders 5,173 2, Lipoid metabolism disorders 3, , Other metabolic disorders 1, Immunity disorders Musculoskeletal conditions 33,972 11, All other musculoskeletal diseases 16, , Other back problems 13, , Other knee disorders 1, Osteoarthritis 1, Rheumatoid arthritis Other shoulder disorders

31 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 29 Medical encounters Individuals affected Bed days Neurologic conditions 8,851 2, All other neurologic conditions 4, , Organic sleep disorders 2, Epilepsy Parkinson disease Other mononeuritis - upper and 230 lower limbs Multiple sclerosis Nutritional disorders 1, Overweight, obesity 1, All other nutritional disorders Protein-energy malnutrition Oral conditions 1,446 1, All other oral conditions 1, , Dental caries Periodontal disease Other neoplasms 4,882 3, All other neoplasms 3, , Benign skin neoplasm Uterine leiomyoma Lipoma Perinatal anomalies 3,798 1, All other perinatal anomalies 1, Low birth weight 1, Birth asphyxia and birth trauma Respiratory disease 16,382 8, All other respiratory diseases 4, , Asthma 4, , Chronic obstructive pulmonary 3,273 disease 37 1, Allergic rhinitis 2, , Chronic sinusitis 1, , Respiratory infections 27,531 17, Upper respiratory infections 17, , Otitis media 6, , Lower respiratory infections 4, , Sense organ diseases 27,759 17, All other sense organ diseases 14, , Refraction/accommodation 6, , Glaucoma 2, ,

32 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 30 Medical encounters Individuals affected Bed days Hearing disorders 2, , Cataracts 2, , Signs and symptoms 50,532 25, All other signs and symptoms 30, , Abdomen and pelvis 10, , Respiratory and chest 9, , Skin disease 21,403 12, All other skin diseases 15, , Contact dermatitis 3, , Sebaceous gland diseases 2, , a Numbers of individuals affected within each diagnosis sub-category may not add to the total number affected for each major category given that individuals may have more than one of the conditions listed within each major category. b Numbers of individuals affected for each major diagnostic category cannot be added to generate a total number of affected individuals due to potential comorbidities; approximately 78,000 non-ad beneficiaries were enrolled at an PRMC facility or known to reside in PRMC in 2012.

33 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 31 Appendix E: Morbidity Burden, Army Non-AD Beneficiaries, North Regional Medical Command (NRMC), CY2012 Figure E-1. Medical Encounters a, Individuals Affected b, and Hospital Bed Days c by Burden of Disease Category, Army Non-AD Beneficiaries, NRMC, CY2012 Medical encounters/individuals affected 1,400,000 1,200,000 1,000, , , , , ,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Bed days Burden of Disease Categories a Data provided by AFHSC; major categories and conditions were adapted from the Global Burden of Disease Study. b Medical encounters: total hospitalizations and ambulatory visits for the condition with no more than one encounter per individual per day per condition. c Individuals with at least one hospitalization or ambulatory visit for the condition. * Bed day estimates exclude bed days at civilian treatment facilities.

34 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 32 Figure E-2. %Medical Encounters by Burden of Disease Category, Army Non-AD Beneficiaries, CY2012 NRMC Army Percent Burden of Disease Categories

35 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 33 Table E-1. Top 10 Medical Conditions by Burden of Disease Category, NRMC Non-AD Beneficiaries, CY Signs/symptoms - other 1. Signs/symptoms - other 1. Maternal - delivery 2. Musculoskeletal - other 2. Upper respiratory infections 2. Pregnancy complications 3. Cardiovascular disease - other 3. Musculoskeletal - other 3. Digestive - other 4. Musculoskeletal - back 4. Signs/symptoms - respiratory/chest 4. Cardiovascular - other 5. Mental disorders - other 5. Skin - other 5. Injury complications 6. Diabetes mellitus 6. Essential hypertension 6. Genitourinary - other 7. Signs/symptoms - respiratory/chest 7. Sense organ disease - other 7. Signs/symptoms - respiratory/chest 8. Skin disease - other 8. Genito-urinary - other 8. Signs/symptoms - other 9. Essential hypertension 9. Signs/symptoms - abdomen/pelvis 9. Lower respiratory disease 10. Mood disorders 10. Cardiovascular disease - other 10. Skin - other

36 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 34 Table E-2. Morbidity Burden Detail, NRMC Non-AD Beneficiaries, CY2012 Blood disorders 107,043 35, Other non-deficiency anemias 46, , All other blood disorders 26, , Iron-deficiency anemia 18, , Other deficiency anemias 11, , Hereditary anemias 3, Cardiovascular disease 866, ,324 4,402 All other cardiovascular diseases 387, , ,937 4 Essential hypertension 265, , Ischemic heart disease 128, , Cerebrovascular disease 81, , Rheumatic heart disease 3, , Inflammatory 1, Congenital anomalies 44,040 18, All other congenital anomalies 35, , Congenital heart disease 5, , Other circulatory anomalies 2, , Diabetes mellitus 278,132 74, Diabetes mellitus 278, , Digestive disease 282, ,179 5,205 All other digestive diseases 193, , ,042 3 Esophagus disease 49, , Other gastroenteritis and colitis 19, , Cirrhosis of the liver 8, , Inguinal hernia 5, , Peptic ulcer disease 3, , Appendicitis 2, , Endocrine disorders 102,688 49, Hypothyroidism 47, , All other endocrine disorders 28, , Other thyroid disorders 26, , Genito-urinary disease 570, ,496 2,627 Nephritis and nephrosis 222, , All other genito-urinary diseases 212, , ,488 6 Menstrual disorders 33, , Other breast disorders 31, , Female genital pain 26, ,

37 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 35 Kidney stones 22, , Benign prostatic hypertrophy 21, , Headache 75,531 42, Headache 75, , Infectious and parasitic disease 224, ,223 1,151 All other infectious and parasitic diseases 164, , STDs 21, , Unspecified viral infection 19, , Diarrheal diseases 12, , Hepatitis B and C 3, , Chlamydia Intestinal nematode infection Tuberculosis Bacterial meningitis Tropical cluster Malaria Injury and poisoning 945, ,069 4,576 Arm and shoulder 231, , Knee 148, , Foot and ankle 120, , Leg 108, , Hand and wrist 66, , Head and neck 65, , Unspecified injury 56, , Back and abdomen 44, , Other complications NOS 42, , ,919 5 Environmental 23, , Other injury from external causes 19, , All other injury 8, , Poisoning, drugs 5, , Poisoning, nondrug 3, , Malignant neoplasms 286,157 46,568 1,616 Breast 47, , Prostate 39, , All other malignant neoplasms 34, , Trachea, bronchus and lung 32, , Melanoma/other skin 30, ,

38 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 36 Lymphoma and multiple myeloma 25, , Colon and rectum 17, , Leukemia 11, , Bladder cancer 10, , Mouth and oropharynx 6, Pancreas 5, Brain 4, Ovary 4, Thyroid 3, , Corpus uteri 3, Esophagus 3, Stomach 2, Liver 2, Cervix uteri 1, Testicular Maternal 136,467 29,448 13,245 Pregnancy complications 79, , ,400 2 Delivery 48, , ,590 1 Ectopic/miscarriage/abortion 6, , Puerperium complications 1, , All other maternal disorders Mental disorders 855, , All other mental disorders 316, , Mood 247, , Anxiety 121, , Adjustment 113, , Substance abuse 25, , Psychotic 21, , Tobacco dependence 4, , Personality 2, Somatoform 1, Metabolic and immunity disorders 156,658 90, Lipoid metabolism disorders 110, , Other metabolic disorders 42, , Immunity disorders 4, Musculoskeletal conditions 1,076, ,428 2,002 All other musculoskeletal diseases 511, , Other back problems 375, ,

39 AIPH 2012 Morbidity Burdens, Army Non-AD Beneficiaries 37 Other knee disorders 87, , Osteoarthritis 61, , Rheumatoid arthritis 23, , Other shoulder disorders 15, , Neurologic conditions 281,396 72, Organic sleep disorders 127, , All other neurologic conditions 107, , Epilepsy 13, , Parkinson disease 13, , Other mononeuritis - upper and lower limbs 9, , Multiple sclerosis 9, , Nutritional disorders 49,544 23, All other nutritional disorders 30, , Overweight, obesity 16, , Protein-energy malnutrition 2, Oral conditions 22,547 16, All other oral conditions 19, , Dental caries 2, , Periodontal disease Other neoplasms 132,719 76, All other neoplasms 98, , Benign skin neoplasm 24, , Uterine leiomyoma 6, , Lipoma 3, , Perinatal anomalies 39,633 9, All other perinatal anomalies 17, , Low birth weight 12, , Birth asphyxia and birth trauma 8, , Respiratory disease 554, ,632 1,779 Chronic obstructive pulmonary disease 159, , Allergic rhinitis 156, , All other respiratory diseases 133, , Asthma 76, , Chronic sinusitis 28, , Respiratory infections 447, ,330 1,623 Upper respiratory infections 232, , Lower respiratory infections 121, , ,460 9 Otitis media 92, ,