Genny M. Maupin

Risk of incident mental health conditions among critical care air transport team members.

BACKGROUND This study investigated whether Critical Care Air Transport Team (CCATT) members are at increased risk for incident post-deployment mental health conditions. METHODS We conducted a retrospective cohort study of 604 U.S. Air Force medical personnel without preexisting mental health conditions who had at least one deployment as a CCATT member during 2003-2012 as compared to a control group of 604 medical personnel, frequency matched based on job role, with at least one deployment during the same period, but without CCATT experience. Electronic health record data were used to ascertain the diagnosis of a mental health condition. RESULTS The incidence of post-deployment mental health conditions was 2.1 per 1000 mo for the CCATT group versus 2.2 per 1000 mo for the control group. The six most frequent diagnoses were the same in both groups: adjustment reaction not including posttraumatic stress disorder (PTSD), anxiety, major depressive disorder, specific disorders of sleep of nonorganic origin, PTSD, and depressive disorder not elsewhere classified. Women were at marginally increased risk and nurses and technicians were at twice the risk of physicians. The distribution of the time interval from end of the most recent deployment to diagnosis of incident mental health condition was positively skewed with a median greater than 6 mo. CONCLUSIONS CCATT members were at no increased risk for incident post-deployment mental health conditions as compared to non-CCATT medical service members. Nearly two-thirds of incident post-deployment mental health conditions were diagnosed outside the standard 6-mo medical surveillance period, a finding warranting further study.

Risk Factors for Incident Postdeployment Mental Health Conditions Among U.S. Air Force Medical Service Personnel

The prevalence of postdeployment mental health (PDMH) conditions in military health care personnel appears to be on par with that of other military personnel. However, there is no comprehensive analysis of incident PDMH conditions within the overall population of U.S. Air Force Medical Service personnel. This study explored the epidemiology of incident PDMH conditions among Air Force Medical Service personnel returning from deployment. A cohort survival analysis was conducted of 24,409 subjects without preexisting mental health conditions and at least one deployment during 2003-2013. Electronic health record data were used to ascertain the diagnosis of a PDMH condition. The primary outcome measure was an incident PDMH condition defined as a mental health diagnosis on at least two separate clinical encounters. The incidence of PDMH conditions was 59.74 per 1,000 person-years. Adjustment, anxiety, mood, sleep, and post-traumatic stress disorders accounted for 78% diagnoses. Protective factors included officer, surgeon, specific enlisted career fields, Air National Guard or Air Force Reserve, and multiple deployments. Risk factors included nurse, other specific enlisted career fields, female, and unmarried with dependents. Most subjects (73%) were diagnosed within the standard 30-month surveillance time period; median time to diagnosis was 13 months.

A 10-Year Cross-Sectional Analysis of Air Force Flight and Operational Medicine Clinic Health Care Services

OBJECTIVES This study described the patient population and the health care services delivered in the Air Force Flight and Operational Medicine Clinics (FOMCs) over the past 10 years. METHODS A cross-sectional analysis was performed on the retrospective cohort of patients who received care at a FOMC from 2003 to 2012. RESULTS A total of 714,157 individuals, generating 4,829,626 encounters, were included in the cohort. They were predominately male service members under the age of 41. One-fifth of individuals were retirees and family members, with one-third being in the pediatric age range. The cohort accessed health care services for three primary reasons: health examinations (28%), occupational dispositions (18%), and primary care (54%). When primary care was sought, the predominate health conditions were upper respiratory infections, back problems, and nontraumatic joint disorders. When services and procedures were a component of the care, they were predominately associated with health examinations involving ophthalmologic, auditory, and cardiac screening tests. Individuals accessing the FOMCs had relatively low need for access to health care services, requiring a median of two annual encounters. CONCLUSIONS This study provided insight into the health care delivered in FOMCs and establishes a foundation for future planning and management of FOMC health care delivery.

Assessment of Deployment-Related Exposures on Risk of Incident Mental Health Diagnoses Among Air Force Critical Care Providers: Nested Case-Control Study.

OBJECTIVES The purpose of this study was to determine the association between deployment-related occupational/environmental exposures and incident postdeployment mental health (PDMH) conditions in a defined population of military health care professionals working in the deployed critical care environment. METHODS A nested case-control study compared cohort members with a PDMH condition (cases, N = 146) with those without a PDMH condition (controls, N = 800) in terms of deployment-related exposures as ascertained using Postdeployment Health Assessment DD 2796 questionnaire data. Multivariable logistic regression models were used to compute odds ratios. RESULTS Nonphysician career fields (i.e., nurses and medical technicians), exposure to dead bodies or people killed/wounded, history of a vehicular accident/crash, exposure to sand/dust, exposure to lasers, and use of mission-oriented protective posture (MOPP) overgarments were associated with increased likelihood for a PDMH condition. The infrequent exposures (i.e., vehicular accident/crash, lasers, and MOPP overgarments) were the exposures most strongly associated with subsequent PDHM conditions. CONCLUSIONS For military health care providers returning from the deployed environment, several exposures are useful for predicting those at increased risk for a PDMH condition. However, there are likely many other important risk factors beyond those captured on the DD 2796 questionnaire.

Finishing What Was Started: An Analysis of Theater Research Conducted From 2010 to 2012

The Joint Combat Casualty Research Team (JC2RT) is part of the human research protection regulatory system implemented in 2005 to oversee the conduct of research in a deployed military combatant command. In 2010, SharePoint, a web-based tool, was established to track study documents. This study conducted by JC2RT no. 13 describes characteristics of research studies under the purview of the JC2RT from 2010 through 2012. Of the 83 research studies reviewed, 34% were completed, 32% were not completed, and 34% were still in progress. Target sample sizes ranged from 12 to 70,000, with 96% of the research studying U.S. military members. The design of 61% of the studies was prospective, 20% surveys, and 14% retrospective reviews. Approximately one-half of the studies were conducted at single sites. Eighty-four percent of the studies that finished an institutional review board (IRB) were completed, whereas a large number of studies never made it to IRB approval. Even after studies have gone through the rigorous process of scientific review and IRB approval some continue to struggle for years to be completed in the theater of operations. The JC2RT is committed to helping facilitate the ethical conduct of research during war.

Examination of the PC-PTSD in previously deployed Air Force Medical Service personnel

ABSTRACT This study assessed the performance of the PC-PTSD in diagnosing postdeployment posttraumatic stress disorder (PTSD) in a cohort of Air Force Medical Services personnel (N = 18,530). The prevalence of PTSD in the cohort was 5.18% based on medical record data. The area under the receiver operating characteristic curve was 0.69, indicating poor classification accuracy. Sensitivity was 47.55%, specificity was 90.68%, positive predictive value was 21.79%, and negative predictive value was 96.94%. The positive and negative likelihood ratios were 5.10 and 0.58, respectively. Several risk factors were found to be associated with a diagnosis of postdeployment PTSD: being a nurse, being enlisted in the medical service career field, being enlisted in the mental health service career field, those over age 30, being a member of the Active Duty service component, and having one’s first deployment be to Iraq. Being an officer was found to be a protective characteristic. These factors could potentially improve screening for PTSD among Air Force healthcare personnel.

Health- and Performance-Related Outcomes in Air Force Medical Service Personnel with a Post-Deployment Mental Health Condition

Background This study examined associations between incident post-deployment mental health (PDMH) conditions and health- and performance-related outcomes in the population of Air Force Medical Service personnel on active duty between 2003 and 2013 who had at least one deployment. Methods Using a posttest-only with nonequivalent groups design, the study cohort was divided into two groups based on the occurrence of an incident PDMH condition, and the groups were then compared in terms of the following health- and performance-related outcomes: health care and pharmaceutical utilization, duty and mobility restrictions, and physical fitness assessment exemptions and composite fitness score. Archival data were extracted from existing databases and associations were assessed using both parametric and nonparametric approaches. Results The cohort comprised 12,216 participants, from which subcohorts were drawn to assess specific outcome measures. Participants with an incident PDMH used health care at 1.8 times the rate and were 6.2 times more likely to be classified as a high utilizer of health care as compared with those without a PDMH condition (controls). They were 2.1-103.0 times more likely to be prescribed one of 22 therapeutic classes of medication and were 2.4 times more likely to have polypharmacy than controls. They were 2.5 times more likely to have a duty or mobility restriction, and the ratio of days spent with a restriction to days without a restriction was 1.8 times that of controls. Lastly, they were 2.4 times more likely to have a physical fitness assessment exemption, but there was no significant difference in the likelihood of a composite fitness score of <90 points. Conclusions The presence of an incident PDMH condition was associated with increased health care and pharmaceutical utilization and decreased occupational performance as assessed in terms of restricted duty status and participation in physical fitness assessments.

Assessment of Deployment-Related Exposures on Risk of Incident Mental Health Diagnoses Among Air Force Medical Service Personnel: Nested Case–Control Study

Background Recent military conflicts in Iraq (Operation Iraqi Freedom), Afghanistan (Operation Enduring Freedom), and elsewhere have been associated with psychological impacts among military personnel. However, relatively little is known about the relationship between those conflicts and psychological health of military health care professionals. Previous work has shown certain demographic factors associated with diagnosed mental health conditions after deployment. However, unique exposures in the deployed environment may be present that are also associated. Understanding the relationship between the demographic factors, exposures, and post-deployment mental health (PDMH) conditions has not been investigated. The purpose of this study was to determine the association between occupational and/or environmental exposures and incident PDMH conditions in a defined population of United States Air Force health care personnel returning from the deployed environment (i.e., deployment-related exposures). Methods A nested case-control study compared cohort members with (N = 4,114) and without (N = 14,073) a PDMH condition in terms of deployment-related occupational and/or environmental exposures. PDMH conditions were identified using the electronic health record and exposures were determined using post-deployment health assessments. Demographic-adjusted multivariable logistic regression models were used to compute odds ratios (ORs). Results The final regression model comprised five exposure and 12 demographic variables. Reported exposures were not strongly associated with incident PDMH conditions (OR ranged from 1.22 to 1.38) and were lower than some demographic factors. Demographic characteristics with relatively large effect sizes (ORs less than 0.5 or greater than 1.5) included the protective factors of Air Force Guardsman (OR: 0.45), reservists (OR: 0.34), and surgeons (OR: 0.32), as well as the risk factor of nurses (OR: 1.51). All model parameters had a p-value less than 0.0001 and the area under the receiver operating characteristic curve was 0.668. Conclusions Given the low area under the receiver operating characteristic, the final statistical model had only marginal performance in its ability to correctly identify cases. Thus, other factors should be studied to identify additional predictors for PDMH conditions.

Pressure Injury Development in Patients Treated by Critical Care Air Transport Teams: A Case-Control Study

&NA; Background The US Air Force transports critically ill patients from all over the world, with transport times commonly ranging from 6 to 11 hours. Few outcome measures have been tracked for these patients. Traditional methods to prevent pressure injuries in civilian hospitals are often not feasible in the military transport environment. Objectives The incidence rate and risk factors are described of en route‐related pressure injuries for patients overseen by the Critical Care Air Transport Team. Methods This retrospective, case‐control, medical records review investigated risk factors for pressure injury in patients who developed a pressure injury after their transport flight compared with those with no documented pressure injuries. Results The pressure injury rate was 4.9%. Between 2008 and 2012, 141 patients in whom pressure injuries developed and who had received care by the team were matched with 141 patients cared for by the team but did not have pressure injury. According to regression analysis, body mass index and 2 or more Critical Care Air Transport Team transports per patient were associated with pressure injury development. Conclusion Although the pressure injury rate of 4.9% in this cohort of patients is consistent with that reported by civilian critical care units, the rate must be interpreted with caution, because civilian study data frequently represent the entire intensive care unit length of stay. Targeted interventions for patients with increased body mass index and 2 or more critical care air transports per patient may help decrease the development of pressure injury in these patients. (Critical Care Nurse. 2018;38[2]:30‐36)

The Performance of the AUDIT-C and the Examination of Risks Associated With Postdeployment Alcohol Misuse in Air Force Medical Service Personnel

This study assessed the performance of the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) in diagnosing a postdeployment alcohol disorder in a cohort of Air Force Medical Services personnel (N = 13,353). The prevalence of alcohol disorders in this population of previously deployed military healthcare personnel was 1.26% based on medical record data. Assessing the AUDIT-C as a screening tool, the following characteristics were found: sensitivity was 23.81%, specificity was 91.48%, positive predictive value was 3.44%, and negative predictive value was 98.95%. The positive and negative likelihood ratios were 2.80 and 0.83, respectively. Classification accuracy of the AUDIT-C was improved by accounting for officer status and female gender. The area under the receiver operating characteristic curve was 0.69 for the multivariable model, indicating poor to fair classification accuracy. However, this model was significantly improved over the univariate model. Thus, taking rank and gender into account when conducting screening may improve the utility of the AUDIT-C.