Assessing the postdeployment quality of treatment for substance use disorders among Army enlisted soldiers in the Military Health System.

Little is known about the rates and predictors of substance use treatment received in the Military Health System among Army soldiers diagnosed with a postdeployment substance use disorder (SUD). We used data from the Substance Use and Psychological Injury Combat study to determine the proportion of active duty (n = 338,708) and National Guard/Reserve (n = 178,801) enlisted soldiers returning from an Afghanistan/Iraq deployment in fiscal years 2008 to 2011 who had an SUD diagnosis in the first 150 days postdeployment. Among soldiers diagnosed with an SUD, we examined the rates and predictors of substance use treatment initiation and engagement according to the Healthcare Effectiveness Data and Information Set criteria. In the first 150 days postdeployment 3.3% of active duty soldiers and 1.0% of National Guard/Reserve soldiers were diagnosed with an SUD. Active duty soldiers were more likely to initiate and engage in substance use treatment than National Guard/Reserve soldiers, yet overall, engagement rates were low (25.0% and 15.7%, respectively). Soldiers were more likely to engage in treatment if they received their index diagnosis in a specialty behavioral health setting. Efforts to improve substance use treatment in the Military Health System should include initiatives to more accurately identify soldiers with undiagnosed SUD. Suggestions to improve substance use treatment engagement in the Military Health System will be discussed.

Postdeployment Polytrauma Diagnoses Among Soldiers and Veterans Using the Veterans Health Affairs Polytrauma System of Care and Receipt of Opioids, Nonpharmacologic, and Mental Health Treatments.

OBJECTIVES: To determine the proportion of Army soldiers who utilized care in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC) within the postdeployment year and to describe prevalence of polytrauma diagnoses, and receipt of opioids, nonpharmacologic treatments (NPTs), and mental health treatments in the VHA during the year following first PSC utilization. SETTING: VHA's 4-tiered integrated PSC network of specialized rehabilitation services for military members and veterans with polytrauma. PARTICIPANTS: Soldiers and veterans who used the PSC during the postdeployment year after an Afghanistan or Iraq deployment ending in fiscal years 2008-2011. DESIGN: Population-based cohort study. MAIN MEASURES: Prevalence of polytrauma diagnoses (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], and chronic pain [CP]), VHA utilization rates of opioid prescriptions, NPT, and specialty mental health treatment within 1 year of PSC utilization. RESULTS: In total, 2.6% of the sample (n = 16 590) used the PSC during the postdeployment year. Among PSC users, CP (76.5%), PTSD (53.1%), and TBI (48.6%) were common and more frequently found together than in isolation; 26.6% filled an opioid prescription, 35.5% received at least 1 NPT, and 83.8% received specialty mental health treatment in the VHA within 1 year of PSC utilization. CONCLUSION: CP was the most common polytrauma condition among PSC users, highlighting the importance of incorporating interdisciplinary pain management approaches within the PSC, with an effort to reduce reliance on long-term opioid therapy and improve rehabilitation.

Predictors of Postdeployment Prescription Opioid Receipt and Long-term Prescription Opioid Utilization Among Army Active Duty Soldiers.

Introduction: Little is known about long-term prescription opioid utilization in the Military Health System. The objectives of this study were to examine predictors of any prescription opioid receipt, and predictors of long-term opioid utilization among active duty soldiers in the year following deployment. Materials and Methods: The analytic sample consisted of Army active duty soldiers returning from deployment to Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn in fiscal years 2008-2014 (N = 540,738). The Heckman probit procedure was used to jointly examine predictors of any opioid prescription receipt and long-term opioid utilization (i.e., an episode of 90 days or longer where days-supply covered at least two-thirds of days) in the postdeployment year. Predictors were based on diagnoses and characteristics of opioid prescriptions. Results: More than one-third of soldiers (34.8%, n = 188,211) had opioid receipt, and among those soldiers, 3.3% had long-term opioid utilization (or 1.1% of the cohort, n = 6,188). The largest magnitude predictors of long-term opioid utilization were receiving a long-acting opioid within the first 30 days of the episode, diagnoses of chronic pain (no specified source), back/neck pain, or peripheral/central nervous system pain, and severe pain score in vital records. Conclusions: Soldiers returning from deployment were more likely to receive an opioid prescription than the overall active duty population, and 1.1% initiated a long-term opioid episode. We report a declining rate of opioid receipt and long-term opioid utilization among Army members from fiscal years 2008-2014. This study demonstrates that the most important predictors of opioid receipt were not demographic factors, but generally clinical indicators of acute pain or physical trauma.

Treatment of Low Back Pain With Opioids and Nonpharmacologic Treatment Modalities for Army Veterans.

BACKGROUND: In the Veterans Health Administration (VHA) there is growing interest in the use of nonpharmacologic treatment (NPT) for low back pain (LBP) as pain intensity and interference do not decrease with opioid use. OBJECTIVES: To describe overall and facility-level variation in the extent to which specific NPT modalities are used in VHA for LBP, either alone or as adjuncts to opioid medications, and to understand associations between veterans' clinical and demographic characteristics and type of treatment. RESEARCH DESIGN: This retrospective cohort study examined use of opioids and 21 specific NPT modalities used by veterans. SUBJECTS: VHA-enrolled Iraq and Afghanistan veterans who utilized care in ("linked" to) 130 VHA facilities within 12 months after their separation from the Army between fiscal years 2008-2011, and who were diagnosed with LBP within 12 months after linkage (n=49,885). MEASURES: Measures included per patient: days' supply of opioids, number of visits for NPT modalities, and pain scores within one year after a LBP diagnosis. RESULTS: Thirty-four percent of veterans filled a prescription for opioids, 35% utilized at least 1 NPT modality, and 15% used both within the same year. Most patients with LBP receiving NPT, on average, had moderate pain (36%), followed by low pain (27%), severe pain (15%), and no pain (11%). Eleven percent had no pain scores recorded. CONCLUSIONS: About 65% of VHA patients with a LBP diagnosis did not receive NPT, and about 43% of NPT users also were prescribed an opioid. Understanding utilization patterns and their relationship with patient characteristics can guide pain management decisions and future study.

Health care utilization among children with chronic conditions in military families.

BACKGROUND: Studies have examined utilization of health care services by civilian children with chronic conditions but not utilization among child dependents of military personnel. OBJECTIVE: To identify children with chronic conditions among military members and retirees and examine their health care utilization and its association with type of condition. METHODS: We derived our sample from child dependents ages birth to 18 years of military personnel with health care enrollment in FY2011. We defined chronic conditions based on diagnoses and repeated specialty care visits. We accrued one year of health care utilization for each child starting with the date of first diagnosis that qualified (i.e., 2 + visits). Health care utilization measures were any inpatient stay; number of outpatient visits (excluding emergency department [ED] visits), ED visits, and number of psychotropic and non-psychotropic prescriptions. RESULTS: Conditions with the highest prevalence were ADHD/conduct disorders (41.2%), other behavioral health (BH) disorders (30.4%), asthma (25.3%) and arthritis (23.8%). Boys and children ages 6-18 were more likely to have BH conditions. Twelve percent had inpatient stays, 63% used the ED, and mean ED visits was 4.6. The mean outpatient visits was 27.9. Utilization was consistently higher for children with both BH and physical health (PH) conditions, children under age 5 (except for number of psychotropic prescriptions), and those enrolled in the military's Extended Health Care Options (ECHO) program. CONCLUSIONS: Prevalence and utilization findings provide data for future service planning and highlight subgroups of children with chronic conditions who may need better access to supportive military programs.

Prevalence of Pain Diagnoses and Burden of Pain Among Active Duty Soldiers, FY2012.

INTRODUCTION: Soldiers are at risk for acute and chronic pain due to the mental and physical challenges of military duties and ongoing training for force readiness. With the burden of pain on any individual attributable across pain sources, a broad perspective that goes beyond prior characterizations of pain is important. We aim to further the understanding of pain's effects among non-deployed active duty soldiers and the Military Health System (MHS), by describing prevalence of 10 painful conditions, reported pain levels, duration of pain and impact of pain on military duty limitations. METHODS: Data are from the MHS Data Repository including outpatient MHS direct care encounters, claims for outpatient purchased care from civilian providers, and vital records, for all soldiers continuously enrolled in TRICARE and not deployed in FY 2012. Ten pain-related diagnostic categories were conceptually derived for this analysis and identified using ICD-9-CM diagnostic codes. We report the FY 2012 prevalence at the soldier-level (N = 297,120) for each pain category as a primary diagnosis, as well as in any diagnostic position, and at the soldier-level for reported pain level, duration, and military duty limitations. Institutional Review Board approval was obtained prior to analyses. RESULTS: Overall, 63% of soldiers had at least one pain diagnosis and 59% had a primary pain diagnosis during FY 2012. Back and neck pain (22%), non-traumatic joint disorders (28%), and other musculoskeletal pain (30%) were the most frequent categories for primary diagnosis. Nearly two-thirds of soldiers had a primary pain diagnosis in more than one category, and 23% in four or more categories. Moderate or severe pain levels were reported at least once during the year by 55% of soldiers who had a primary pain diagnosis. In the subsample of soldiers with primary pain in the first quarter, duration and chronicity of pain diagnoses varied by pain category: the back and neck pain category was the most common for both persistent pain occurring in each quarter of FY 2012 (23%) and chronic pain lasting for at least 3 mo (62%). In most pain categories, the majority of soldiers were released without duty limitations. CONCLUSION: These data provide a deeper understanding of pain diagnoses and burden of pain among active duty soldiers. A substantial proportion of soldiers with pain diagnoses were seen for pain self-reported as only mild, or that did not result in significant restrictions in military duty limitations. However, given the prevalence of multiple pain diagnoses and common reports of moderate or severe pain and long duration, complex interventions may be required to minimize the effect of pain on force readiness. This encounters-based analysis is likely an underestimate of presence of pain, and does not include contextual factors that could better describe the true effect of pain among this population.

Associations of Early Treatments for Low-Back Pain with Military Readiness Outcomes.

BACKGROUND: Chronic low-back pain (LBP) is a frequent cause of work absence and disability, and is frequently associated with long-term use of opioids. OBJECTIVE: To describe military readiness-related outcomes at follow-up in soldiers with LBP grouped by the type of early treatment received for their LBP. Treatment groups were based on receipt of opioid or tramadol prescription and receipt of nonpharmacologic treatment modalities (NPT). Design, Subjects, Measures: A retrospective longitudinal analysis of U.S. soldiers with new LBP episodes persisting more than 90 days between October 2012 and September 2014. Early treatment groups were constructed based on utilization of services within 30 days of the first LBP claim. Outcomes were measured 91-365 days after the first LBP claim. Outcomes were constructed to measure five indicators of limitations of military readiness: military duty limitations, pain-related hospitalization, emergency room visit for LBP, pain score of moderate/severe, and prescription for opioid/tramadol. RESULTS: Among soldiers with no opioid receipt in the prior 90 days, there were 30,612 new episodes of LBP, which persisted more than 90 days. Multivariable logistic regression models found that compared to the reference group (no NPT, no opioids/tramadol receipt), soldiers who received early NPT-only had lower likelihoods for military duty limitations, pain-related hospitalization, and opioid/tramadol prescription at follow-up, while soldiers' that started with opioid receipt (at alone or follow-up in conjunction with NPT) exhibited higher likelihoods on many of these negative outcomes. CONCLUSION: This observational study of soldiers with a new episode of LBP and no opioid receipt in the prior 90 days suggests that early receipt of NPT may be associated with small, significant gains in ability to function as a soldier and reduced reliance on opioid/tramadol medication. While further research is warranted, increased access to NPT at the beginning of LBP episodes should be considered.

Postdeployment Behavioral Health Screens and Linkage to the Veterans Health Administration for Army Reserve Component Members.

OBJECTIVE: Approximately three to six months after returning from deployment, military service members complete the Post-Deployment Health Reassessment (PDHRA), which includes screens for alcohol misuse, depression, and posttraumatic stress disorder (PTSD). To determine whether Army Reserve Component (RC) members (Army National Guard and Army Reserve) with positive screening scores on the PDHRA receive needed care, the investigators examined the association between positive scores and enrollment and utilization of care ("linkage") in the Veterans Health Administration (VHA), as well as rescreening scores, diagnosis, and behavioral treatment in VHA. METHODS: Mixed-effects regression models were used to predict linkage to VHA within six months after RC members (N=73,164) completed the PDHRA, with alcohol misuse, depression, and PTSD screen scores as key independent variables. Regression models were stratified by gender and National Guard versus Reserve status. Among those who linked to VHA (N=25,168), screening scores and subsequent diagnosis and treatment in VHA were also examined. RESULTS: Army RC members with positive PTSD and depression screening scores were more likely than those with negative screens to link to VHA, and most (54%-84%) received VHA treatment once diagnosed. Positive screens for alcohol misuse were associated with linkage to VHA for men but not for women, and treatment rates for alcohol use disorders were relatively low (0%-25%) for both men and women diagnosed as having an alcohol use disorder. CONCLUSIONS: The finding that Army RC members with greater indications of behavioral health problems linked to VHA is encouraging. However, more outreach and treatment engagement strategies could be directed to those with alcohol use disorder, particularly women.

Pre-deployment Year Mental Health Diagnoses and Treatment in Deployed Army Women.

We estimated the prevalence of select mental health diagnoses (MHDX) and mental health treatment (MHT), and identified characteristics associated with MHT during the pre-deployment year (365 days before deployment) in active duty Army women (N = 14,633) who returned from Iraq or Afghanistan deployments in FY2010. Pre-deployment year prevalence estimates were: 26.2 % for any select MHDX and 18.1 % for any MHT. Army women who had physical injuries since FY2002 or any behavioral health treatment between FY2002 and the pre-deployment year had increased odds of pre-deployment year MHT. During the pre-deployment year, a substantial percentage of Army women had MHDX and at least one MHT encounter or stay. Future research should determine if pre-deployment MHDX among Army women reflect vulnerability to future MHDX, or if pre-deployment MHT results in protection from chronic symptoms.

Traumatic Brain Injury and Post-Deployment Binge Drinking among Male and Female Army Active Duty Service Members Returning from Operation Enduring Freedom/Operation Iraqi Freedom.

This study examines whether the relationship between traumatic brain injury (TBI) and post-deployment binge drinking is independent of screening positive for mental health problems among male and female service members. Data are from the Substance Use and Psychological Injury Combat Study of Army members returning from deployment to Afghanistan or Iraq in fiscal years 2008-2011. The sample consists of 240,694 male and 26,406 female active duty members who completed initial and follow-up questionnaires. The initial questionnaire, completed at the end of deployment, included screens for TBI and mental health problems (post-traumatic stress disorder, depression, harmful thoughts). The dependent variable, frequent binge drinking (six or more drinks on one occasion, at least monthly), was assessed on the follow-up questionnaire on average 3-9 months post-deployment. More than 21% of males and 7% of females reported frequent binge drinking. Male members were more likely to screen positive for TBI, compared with females (7.5% vs. 4.4%). Females with both TBI and mental health positive screens had more than double the risk of frequent binge drinking, compared with those without either problem (15.8% vs. 6.6%), and males with both problems had almost double the risk, compared with males with neither problem (33.6% vs. 19.7%). In multivariable logistic regression models, having a TBI and a comorbid positive mental health screen was associated with increased odds of frequent binge drinking among both males and females (adjusted odds ratio [AOR] = 1.59, CI: 1.50-1.69, and AOR = 2.11, CI: 1.57-2.83, respectively), compared with those with neither condition. More research is needed on the interaction of gender and binge drinking, especially when TBI and mental health problems co-exist.

Time-varying associations of suicide with deployments, mental health conditions, and stressful life events among current and former US military personnel: a retrospective multivariate analysis.

BACKGROUND: US military suicides have increased substantially over the past decade and currently account for almost 20% of all military deaths. We investigated the associations of a comprehensive set of time-varying risk factors with suicides among current and former military service members. METHODS: We did a retrospective multivariate analysis of all US military personnel between 2001 and 2011 (n=110 035 573 person-quarter-years, representing 3 795 823 service members). Outcome was death by suicide, either during service or post-separation. We used Cox proportional hazard models at the person-quarter level to examine associations of deployment, mental disorders, history of unlawful activity, stressful life events, and other demographic and service factors with death by suicide. FINDINGS: The strongest predictors of death by suicide were current and past diagnoses of self-inflicted injuries, major depression, bipolar disorder, substance use disorder, and other mental health conditions (compared with service members with no history of diagnoses, the hazard ratio [HR] ranged from 1·4 [95% CI 1·14-1·72] to 8·34 [6·71-10·37]). Compared with service members who were never deployed, hazard rates of suicide (which represent the probability of death by suicide in a specific quarter given that the individual was alive in the previous quarter) were lower among the currently deployed (HR 0·50, 95% CI 0·40-0·61) but significantly higher in the quarters following first deployment (HR 1·51 [1·17-1·96] if deployed in the previous three quarters; 1·14 [1·06-1·23] if deployed four or more quarters ago). The hazard rate of suicide increased within the first year of separation from the military (HR 2·49, 95% CI 2·12-2·91), and remained high for those who had separated from the military 6 or more years ago (HR 1·63, 1·45-1·82). INTERPRETATION: The increased hazard rate of death by suicide for military personnel varies by time since exposure to deployment, mental health diagnoses, and other stressful life events. Continued monitoring is especially needed for these high-risk individuals. Additional information should be gathered to address the persistently raised risk of suicide among service members after separation. FUNDING: Partly funded by the Naval Research Program.

The Association of Combat Exposure With Postdeployment Behavioral Health Problems Among U.S. Army Enlisted Women Returning From Afghanistan or Iraq.

An association between combat exposure and postdeployment behavioral health problems has been demonstrated among U.S. military service members returning from Afghanistan or Iraq in predominantly male samples, yet few studies have focused on the experiences of women. Using data from the longitudinal, observational Substance Use and Psychological Injury Combat (SUPIC) Study, we explored the self-report of 4 combat exposure items and postdeployment behavioral health screening results for 42,397 Army enlisted women who had returned from Afghanistan or Iraq from fiscal years 2008 through 2011. We ran multivariate logistic regression models to examine how a constructed composite combat exposure score (0, 1, 2, 3+) was associated with screening positive postdeployment for posttraumatic stress disorder (PTSD), depression, and at-risk drinking among active duty (AD) and National Guard/Reserve (NG/R) women. AD and NG/R women commonly reported being wounded, injured, assaulted, or hurt (17.3% and 29.0%, respectively). In all 6 multivariate models, Army women with any report of combat exposure had increased odds of the behavioral health problem (i.e., PTSD, depression, or at-risk drinking). The magnitude of the association between combat exposure and PTSD was most striking, indicating increased odds of PTSD as combat exposure score increased. AD and NG/R women with a combat exposure score of 3+ had increased odds of PTSD, 20.7, 95% confidence interval (CI) [17.0, 25.1] and 27.8, 95% CI [21.0, 36.9], respectively. Women who report combat exposure may benefit from early prevention and confidential intervention to promote postdeployment health and reduce long-term behavioral health problems.

Reliability of the Deployment Resiliency Assessment.

This article describes the reliability of the instruments embedded in a mental health screening instrument designed to detect risky drinking, depression, and post-traumatic stress disorder among members of the Armed Forces. The instruments were generally reliable, however, the risky drinking screen (Alcohol Use Disorders Identification Test-Consumption) had unacceptable reliability (α = 0.58). This was the first attempt to assess psychometric properties of a screening and assessment instrument widely used for members of the Armed Forces.

Predictors of Positive Illicit Drug Tests After OEF/OIF Deployment Among Army Enlisted Service Members.

OBJECTIVE: To identify characteristics associated with testing positive for illicit drugs postdeployment among Army enlisted members. METHODS: Army active duty and National Guard/Reserve enlisted members returning from Operation Enduring Freedom/Operation Iraqi Freedom deployments in fiscal years 2008 to 2011, who submitted urine specimens for random and other illicit drug tests up to 3 years postdeployment, were included. Multiple logistic regression models, stratified by component, identified demographic and deployment characteristics associated with any positive drug test (cocaine, heroin, tetrahydrocannabinol [marijuana], or amphetamine) during the 3 years postdeployment. RESULTS: Among Army active duty and National Guard/Reserve enlisted members, respectively, 3.46% (95% confidence interval 3.40-3.52) and 3.84% (confidence interval 3.74-3.94) tested positive for 1+ illicit drugs during the 3 years postdeployment; the vast majority for marijuana. Relative to other groups, increased odds of a positive drug test were found for members with a combat specialist occupation, or first deployers. CONCLUSION: Almost 4% of Army members tested positive for illicit drug use within 3 years of return from deployment. Early identification and intervention with enlisted members who are more likely to test positive for illicit drug use should be explored to see if it will enhance health and reduce illegal drug use after deployment to a war zone.

Combat-Acquired Traumatic Brain Injury, Posttraumatic Stress Disorder, and Their Relative Associations With Postdeployment Binge Drinking.

OBJECTIVE: To examine whether experiencing a traumatic brain injury (TBI) on a recent combat deployment was associated with postdeployment binge drinking, independent of posttraumatic stress disorder (PTSD). METHODS: Using the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel, an anonymous survey completed by 28 546 personnel, the study sample included 6824 personnel who had a combat deployment in the past year. Path analysis was used to examine whether PTSD accounted for the total association between TBI and binge drinking. MAIN MEASURES: The dependent variable, binge drinking days, was an ordinal measure capturing the number of times personnel drank 5+ drinks on one occasion (4+ for women) in the past month. Traumatic brain injury level captured the severity of TBI after a combat injury event exposure: TBI-AC (altered consciousness only), TBI-LOC of 20 or less (loss of consciousness up to 20 minutes), and TBI-LOC of more than 20 (loss of consciousness >20 minutes). A PTSD-positive screen relied on the standard diagnostic cutoff of 50+ on the PTSD Checklist-Civilian. RESULTS: The final path model found that while the direct effect of TBI (0.097) on binge drinking was smaller than that of PTSD (0.156), both were significant. Almost 70% of the total effect of TBI on binge drinking was from the direct effect; only 30% represented the indirect effect through PTSD. CONCLUSION: Further research is needed to replicate these findings and to understand the underlying mechanisms that explain the relationship between TBI and increased postdeployment drinking.

Army Active Duty Members' Linkage to Veterans Health Administration Services After Deployments to Iraq or Afghanistan and Following Separation.

This study described the rate and predictors of Operation Enduring Freedom/Operation Iraqi Freedom active duty Army members' enrollment in and use of Veterans Health Administration (VHA) services (linkage), as well as variation in linkage rates by VHA facility. We used a multivariate mixed effect regression model to predict linkage to VHA, and also calculated linkage rates in the catchment areas of each facility (n = 158). The sample included 151,122 active duty members who deployed to Iraq or Afghanistan and then separated from the Army between fiscal years 2008 and 2012. Approximately 48% of the active duty members separating utilized VHA as an enrollee within one year. There was significant variation in linkage rates by VHA facilities (31-72%). The most notable variables associated with greater linkage included probable serious injury during index deployment (odds ratio = 1.81), separation because of disability (odds ratio = 2.86), and various measures of receipt of VHA care before and after separation. Information about the individual characteristics that predict greater or lesser linkage to VHA services can be used to improve delivery of health care services at VHA as well as outreach efforts to active duty Army members.

Factors associated with psychiatric evacuation among service members deployed to Operation Enduring Freedom and Operation Iraqi Freedom, January 2004 to September 2010.

OBJECTIVES: To calculate the annual rate of psychiatric evacuation of U.S. Service members out of Iraq and Afghanistan and identify risk factors for evacuation. METHODS: Descriptive and regression analyses were performed using deployment records for Service members evacuated from January 2004 through September 2010 with a psychiatric diagnosis, and a 20% random sample of all other deployers (N = 364,047). RESULTS: A total of 5,887 deployers psychiatrically evacuated, 3,951 (67%) of which evacuated on first deployment. The rate increased from 72.9 per 100,000 in 2004 to 196.9 per 100,000 in 2010. Evacuees were overrepresented in both combat and supporting duty assignments. In multivariate analysis, Army active duty had the highest odds of evacuation relative to Army National Guard (adjusted odds ratio [AOR] 0.852, 95% confidence interval [CI] 0.790-0.919), Army Reserve (AOR 0.825, 95% CI 0.740-0.919), and all other components. Accessions in 2005 had the highest risk (AOR 1.923, 95% CI 1.621-2.006) relative to pre-2001 accessions. CONCLUSIONS: Risk for psychiatric evacuation is highest among the Army Active Component. A strong link between multiple deployments or combat-related exposure and psychiatric evacuation is not apparent. Increased risk among post-2001 accessions suggests further review of changes in recruitment, training, and deployment policies and practices.

Predictors of Army National Guard and Reserve members' use of Veteran Health Administration health care after demobilizing from OEF/OIF deployment.

This study described rates and predictors of Army National Guard and Army Reserve members' enrollment in and utilization of Veteran Health Administration (VHA) services in the 365 days following demobilization from an index deployment. We also explored regional and VHA facility variation in serving eligible members in their catchment areas. The sample included 125,434 Army National Guard and 48,423 Army Reserve members who demobilized after a deployment ending between FY 2008 and FY 2011. Demographic, geographic, deployment, and Military Health System eligibility were derived from Defense Enrollment Eligibility Reporting System and "Contingency Tracking System" data. The VHA National Patient Care Databases were used to ascertain VHA utilization and status (e.g., enrollee, TRICARE). Logistic regression models were used to evaluate predictors of VHA utilization as an enrollee in the year following demobilization. Of the study members demobilizing during the observation period, 56.9% of Army National Guard members and 45.7% of Army Reserve members utilized VHA as an enrollee within 12 months. Demographic, regional, health coverage, and deployment-related factors were associated with VHA enrollment and utilization, and significant variation by VHA facility was found. These findings can be useful in the design of specific outreach efforts to improve linkage from the Military Health System to the VHA.