A state-by-state and regional analysis of the direct medical costs of treating musculoskeletal injuries among US Army trainees.

INTRODUCTION: Low physical activity (PA) and physical fitness (PF) are well-known factors for chronic diseases generally and cardiovascular diseases specifically. The economic burden from these chronic diseases is also well documented, as is their disproportionate prevalence among states in the Southern region of the U.S. Low PA and PF have also become recognized factors impacting military readiness and national security. Specifically, low PA and PF are highly correlated with musculoskeletal injures (MSKIs), now considered the greatest medical impediment to military readiness. Prior research shows low PF and MSKI incidence are greater among Army recruits from Southern states, however no previous research has investigated the economic impact of MSKIs at the state- and regional-level. The aim of this study was to determine the economic impact of MSKIs among U.S. Army initial military trainees on a state- and regional-basis. METHODS: Rosters for recruits entering U.S. Army Initial Military Training (IMT) for fiscal year 2017 were obtained (n = 103,487). Roster data included the unique personal identifier, demographics with postal zip code, training start/end dates, and height and weight and were subsequently linked to medical encounters and cost data from the Military Health System Data Repository. Trainees with one or more MSKIs were considered injury cases (n = 33,509) and were stratified by gender. The percent of trainee MSKI cases was calculated as number of injury cases divided by total number of trainees. For each injury case, the direct medical cost for MSKIs was calculated. The percent of trainees and direct medical costs for MSKIs were aggregated to home-state and regional-levels for the four U.S. Census tract regions. A test for equality of proportions was performed at state- and regional-levels to investigate differences in percent of trainees with MSKIs by state/region. A one-way ANOVA was used to investigate possible differences in medical cost/trainee by region. RESULTS: 34% (n = 33,509) of all trainees sustained at least one MSKI. State-specific MSKI percentages showed ten states having the greatest percentage of trainees with at least one MSKI, eight of which were from the South region (AL, FL, GA, LA, MS, NC, SC, TN). The South was the only region to have a statistically significantly higher percentage of trainees with MSKIs at 34% (p < 0.001), as compared to all other regions. The total direct medical cost of treating MSKIs among all trainees was $14,891,563. The South was the costliest region ($7,168,997), accounted for nearly 50 % of the total national cost, and had the highest mean MSKI cost/trainee. DISCUSSION: This study was the first in demonstrating the disproportionate economic burden Southern states pose to the U.S. Department of Defense resulting from its significantly higher MSKI cost. PA and PF are known to ameliorate chronic disease and MSKI burden among general and military populations. Therefore, increasing PA and PF among all young Americans, and specifically those living in Southern states, is imperative for improving public health and reducing the economic and practical burden of MSKIs on military readiness and national security.

Estimates of Direct Medical and Indirect Costs Associated With COVID-19 Among U.S. Active Duty Army Soldiers.

INTRODUCTION: This study estimated the direct medical and indirect costs associated with coronavirus disease 2019 (COVID-19) diagnoses among U.S. active duty (AD) Army service members (SMs). These cost estimates provide the U.S. Military with a better understanding of the financial burden of COVID-19 and provide a foundation for cost-effectiveness estimates. MATERIALS AND METHODS: The study was approved as Public Health Practice (#17-605) by the U.S. Army Public Health Center, Public Health Review Board. U.S. AD Army SMs with COVID-19 were identified using an Army COVID-19 testing and surveillance database. Encounters for these SMs were captured from medical record where International Classification of Disease Tenth Revision, Clinical Modification code U07.1 was in the first or second diagnostic position. Analyses were conducted on SMs with COVID-19 who either had no healthcare encounters in the Military Health System (MHS); at least one MHS COVID-19 inpatient hospitalization; or at least one MHS outpatient COVID-19 encounter. Coronavirus disease 2019 (COVID-19) costs captured from the encounters were used to develop direct medical cost estimates. Literature on COVID-19 recovery post-hospitalization, along with the number of COVID-19 hospitalizations and outpatient visits from encounters were used to describe the intensity of COVID-19 care. Estimates of the indirect cost of lost duty were based on SMs salary information, along with recovery time, bed days, or outpatient visit time. The indirect cost of limited duty was estimated using the time associated with the Department of Defense (DoD) COVID-19 pandemic mitigation strategies in place when these SMs were identified as positive for COVID-19. RESULTS: Coronavirus disease 2019 (COVID-19) cost estimates were developed for the Army using data from 19,086 SMs identified as positive for COVID-19 between June 1, 2020, and December 31, 2020. Direct medical costs, or the amount paid by the DoD to facilities for COVID-19 care, averaged $606 per SM with an encounter. Indirect costs for lost duty or the cost for recovery and the time taken to seek care for COVID-19 averaged $319 per SM, while indirect costs for limited duty or isolation associated with COVID-19 averaged $4,111 per SM or $411 per day. Service members (SMs) with an inpatient hospitalization averaged 4.8 bed days (range 1-43) and 266 recovery hours while SMs who sought outpatient care for COVID-19 averaged two outpatient visits (range 1-60 visits). CONCLUSIONS: The direct medical costs of a COVID-19 encounter in the MHS ($606) are a small portion of the costs for a SM with COVID-19. Indirect costs of lost and limited duty associated with COVID-19 averaged seven times higher ($4,331) and accounted for the vast majority of costs. Recognition of these costs is important especially given that soldiers in the hospital or in quarters being quarantined are complete losses of manpower to the Army. While the COVID-19 pandemic is ongoing and prevention, treatment, and mitigation efforts continue to evolve, having reliable estimates of direct medical and indirect costs from this study allows the U.S. Army and MHS to better account for the cost of this pandemic for its population.

The cost of lower extremity fractures among active duty U.S. Army soldiers, 2017.

The estimated cost to the Army for lower extremity fractures in 2017 was approximately $116 million. Direct medical expenses totaled $24 million, and indirect medical costs totaled $92 million ($900 thousand lost duty; $91 million limited duty). Foot and toe fractures, along with lower leg and ankle fractures accounted for the majority of soldiers' initial visits for care (n=4,482; 91.6%), and more than $103 million (89.0%) of overall costs ($116 million). Costs varied by location of care. In outpatient settings, initial visits for foot and toe injuries accounted for the highest costs: $49 million overall. Direct medical costs totaled $1.2 million, and indirect medical costs (limited duty) were $48 million. Conversely, in inpatient settings, lower leg and ankle fractures accounted for slightly more than half of all costs (overall $9 million; $4.8 million in direct medical costs and $4.5 million in indirect medical costs). The finding that the majority of costs related to lower extremity fractures were due to estimated days of lost or limited duty and associated loss of productivity justifies the inclusion of indirect cost estimates as a part of overall injury cost calculations.

Financial costs to the U.S. Army for suicides by newly enlisted Soldiers.

OBJECTIVE: To estimate the financial burden to the U.S. Army of suicide by enlisted Soldiers during their first year of service. METHODS: This analysis included new Army enlisted Soldiers who started initial entry training from October 2012 through September 2016 and subsequently died by suicide within their first year of service. Outpatient and inpatient direct medical, direct nonmedical, recruiting, and training costs to the Army were calculated. RESULTS: During the 48-month observational study period, 29 Soldiers died by suicide within their respective first year of service. The described financial costs accrued by the Army as a result of these deaths were $152,271-with an average of $6,091 per healthcare utilizer. Recruiting and training costs were $1,115,860 for all suicide cases. CONCLUSION: Average direct cost per healthcare utilizer increased during a Soldier's first year of service. This may be associated with the transition through different phases of training and to the first operational duty station. PUBLIC HEALTH IMPLICATIONS: Results obtained through this cost-of-illness analysis may serve as baseline metrics to inform future cost-effectiveness studies.

Prevalence of selected underlying health conditions among active component Army service members with coronavirus disease 2019, 11 February-6 April 2020.

The novel coronavirus (severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) is exhibiting widespread community transmission throughout most of the world. Previous reports have evaluated the risk of serious illness in civilians diagnosed with COVID-19; however, similar reports have not been compiled for the Army active component (AC) population. COVID-19 has been a reportable condition for the Department of Defense since 5 February 2020, and, as of the morning of 6 April, a total of 873 cases were reported to the Disease Reporting System internet from Army installations. Of these cases, a total of 219 (25.1%) were identified as Army AC service members. The majority of these cases did not require hospitalization (n=207; 94.5%). The most common comorbidities present in nonhospitalized cases included other chronic illnesses (43.5%), neurologic disorders (24.6%), and obesity (21.7%). Overall, 12 cases (5.5%) required hospitalization. Hospitalized cases had a history of obesity (58.3%), neurologic disorder (50.0%), other chronic illnesses (41.7%), and hypertension (25.0%). No comorbidities were present among 27.1% (n=56) of nonhospitalized cases and 25.0% (n=3) of hospitalized cases.

Incidence, timing, and seasonal patterns of heat illnesses during U.S. Army basic combat training, 2014-2018.

Risk factors for heat illnesses (HIs) among new soldiers include exercise intensity, environmental conditions at the time of exercise, a high body mass index, and conducting initial entry training during hot and humid weather when recruits are not yet acclimated to physical exertion in heat. This study used data from the Defense Health Agency's-Weather-Related Injury Repository to calculate rates and to describe the incidence, timing, and geographic distribution of HIs among soldiers during U.S. Army basic combat training (BCT). From 2014 through 2018, HI events occurred in 1,210 trainees during BCT, resulting in an overall rate of 3.6 per 10,000 BCT person-weeks (p-wks) (95% CI: 3.4-3.8). HI rates (cases per 10,000 BCT p-wks) varied among the 4 Army BCT sites: Fort Benning, GA (6.8); Fort Jackson, SC (4.4); Fort Sill, OK (1.8); and Fort Leonard Wood, MO (1.7). Although the highest rates of HIs occurred at Fort Benning, recruits in all geographic areas were at risk. The highest rates of HI occurred during the peak training months of June through September, and over half of all HI cases affected soldiers during the first 3 weeks of BCT. Prevention of HI among BCT soldiers requires relevant training of both recruits and cadre as well as the implementation of effective preventive measures.

The Etiology of Injuries in US Army Initial Entry Training.

BACKGROUND: US Army initial entry training (IET) trainees engage in intense physical activities for 10 or more weeks prior to their assignment to operational units. Many trainees succumb to injury during IET. Injuries to the lower extremities and back have historically been the most common, and thus have been the focus of routine health surveillance. OBJECTIVES: The primary goal of this analysis was to verify the training-related injuries of greatest concern and to update the clinical diagnostic codes (ICD-10-CM) used in surveillance. The investigation also aimed to develop a sense of the financial magnitude of these injuries. METHODS: The distribution of all IET injuries was determined using a comprehensive injury taxonomy. Injuries were categorized based on causal energy source (mechanical, thermal, radiant, nuclear, chemical, or electrical). Mechanical energy transfers included acute trauma and cumulative microtrauma ("overuse"). Injury ICD-10-CM codes were identified in calendar year 2016 IET trainees' electronic healthcare records. Injury frequencies were reported for gender, body region, and injury type. Costs were calculated from medical encounters and estimated lost training time using the most frequently injured anatomical site as a baseline. RESULTS: Among 106,367 trainees, 65,026 separate injuries were identified. Mechanical energy transfers to lower extremities caused 75% of all injuries; most (65%) were cumulative microtraumatic. The most frequently injured anatomical site (the knee, 20% of injuries), is estimated to have cost over $39 million. CONCLUSIONS: Lower extremity injuries, followed by those of the low back continue to be leading "training-related injuries". This suggests the need to ensure distances and/or frequencies of weight-bearing activities (running, foot-marching) are not increased too rapidly or too excessively, and that trainees' fitness prior to IET is adequate. Medical costs and lost training time should be included in future monitoring.