The changing profile of disability in the U.S. Army--a study: costs, seeking causes, and hoping to positively impact change.

Disability in both the military and civilian communities is growing more costly, with billions of dollars spent annually in both communities. The costs are felt not only financially, with dollars spent on healthcare, the loss of trained and expert personnel, and lost income, but in a variety of other ways, including reduced ability to engage fully in day-to-day activities and subsequent overall decreased quality of life. A research group has undertaken a study of disability in the United States Army, funded by a grant from the U.S. Army Medical Research and Materiel Command. This first of five planned studies has been published in Disability and Health Journal, January 2008. The group analyzed disability data spanning 25 years, from 1981-2005. Excerpts of the study appear here, followed by an interview EP conducted with Dr. Nicole Bell, a co-author of the study. A full copy of the report can be found at the Disability and Health Journal Web site (http://www.disabilityandhealthjnl.com).

Abstract Excerpt

Background: We sought to provide a profile of U.S. Army soldiers discharged with a permanent disability and to clarify whether underlying demographic changes explain increasing risks.

Results: Disability risk has increased seven-fold over the past 25 years. In 2005, there were 1,262 disability discharges per 100,000 active-duty soldiers. Risk factors include female gender, lower rank, married or formerly married, high school education or less, and age 40 or younger. Army population demographics changed during this time; the average age and tenure of soldiers increased, and the proportion of soldiers who were officers, women, and college educated grew. Adjusting for these demographic changes did not explain the rapidly increasing risk of disability. Time-series models revealed that disability among women is increasing independently of the increasing number of women in the Army; disability is also increasing at a faster pace for younger, lower-ranked, enlisted, and shorter-tenured soldiers.

Conclusion: Disability is costly and growing in the Army. Temporal changes in underlying Army population demographics do not explain overall disability increases. Disability is increasing most rapidly among female, junior enlisted, and younger soldiers.

Study Excerpt

Between 1981 and 2002, the number of active-duty Army personnel fell by 37 percent as part of an overall downsizing effort. At the same time, soldiers reported poorer physical and mental health and increased levels of stress, depression, anxiety, and occupational stress compared with their civilian peers; these factors may be associated with increased risk for subsequent disability.

DoD (Department of Defense) Directive 1332.18 and 10 U.S. Code, Ch. 61 outline the requirements and procedures for separations due to a physical disability with the primary requirement being that the soldier must be unfit to carry out duties of his or her rank, office, or grade due to a physically disabling condition that substantially limits or precludes fulfillment of the purpose of their active-duty employment.

Causes or major types of disability are defined in the Veterans Administration Schedule for Rating Disabilities (VASRD). They fall into the following categories: musculoskeletal conditions; neurological conditions; mental health disorders; cardiovascular conditions; respiratory conditions; endocrine disorders; digestive conditions; diseases of the eye; skin disorders; genitourinary conditions; infectious diseases, immune disorders, and nutritional disease; hemic and lymphatic disorders; diseases of the ear; diseases of other sensory organs; gynecological conditions; and dental and oral conditions.

Musculoskeletal-related disability is the fastest growing category of disability, increasing from 70 per 100,000 in 1981 to 950 per 100,000 by 2005.

Disability discharge risks are 7 times higher today than they were 25 years ago. The increase appears primarily attributable to disorders of the musculoskeletal system. Preliminary findings (in unadjusted models) indicate that rates of musculoskeletal-related disability are increasing faster than any other type of disability and the increase is occurring more rapidly among women, whites, blacks, those without a college education, and soldiers aged 35 or younger. By 2005 more than 7,000 people with life-altering disabilities were being discharged from the Army, even before the full impact of conditions related to deployment in support of Operation Iraqi Freedom had a chance to work through the system.

This is only a fraction of the problem as it does not include soldiers who have disabling conditions but nonetheless seek evaluation and treatment for their conditions in the VA (Department of Veterans Affairs) or through other healthcare systems only after their discharge from the Army (as it is their right to do). There is currently no mechanism in place to link DoD and VA data resulting in a discontinuity of service over time and an inability to explore individual-level healthcare data longitudinally.

Ideally, soldiers seeking care outside of either the VA or DoD compensation programs should also be identified and followed.

Because the Army only discharges individuals with conditions that preclude active service while the VA also provides compensation for functional limitations caused or aggravated by military service, both systems need to be evaluated in order to fully appreciate the magnitude and characteristics of service-connected disability.

Dr. Bell provided information on the details of the group's research:

Nicole Bell, ScD, MPH (NB): We do secondary data analysis, which means we combine information from a wide range of administrative and health-related military databases (personnel records, hospital records, disability files, health and behavioral surveys, etc.). The advantage of this approach is it allows us to look at a lot of different factors on a very large population fairly rapidly. The disadvantage of this approach is we can't always answer the specific questions that we most want answered. We are limited by the data that has already been collected.

It can be difficult to study the problem of disability among military populations because of loss of follow-up. When servicemembers leave the Armed Forces after their military tenure, we often can't follow them. Even if they continue to receive care in the VA system, we may not be able to access data on them due to restrictions and limitations in data sharing. Moreover, the data we have on disability is likely just the tip of the iceberg since many who may have experienced a service-related disability may not be eligible for compensation and for this reason, or others, may not seek disability evaluation. Consequences of some problems may not be realized until well after they have left the military and thus may not be included in Army disability files.

Exceptional Parent (EP): What prompted your group to undertake this study?

NB: Most of our earlier research focused on the topic of acute injury (both intentional and unintentional), as these are by far the most common causes of morbidity for active-duty soldiers. Whether we consider the economic or quality-of-life costs, we soon learned that perhaps the most significant consequence of injury was permanent physical disability. Therefore, a shift to the study of the natural history of injury-related disability was a logical one for our research group. We actually started studying disability alongside some of our other acute injury studies several years ago. We collaborated with a VA study team in a pilot test of how well active-duty Army injury exposure and disability outcome data could be linked to VA data from soldiers who leave the army and are ultimately treated by the VA for knee- or back-related disabilities. Data sharing restrictions made this a challenging undertaking, but we learned a lot in the process. For example, we learned that not all soldiers who are eligible to receive VA care necessarily seek/receive post-active-duty care at the VA. Likewise, many individuals whose disabilities are not recorded by the Army before they are discharged are nonetheless rated and oftentimes treated by the VA subsequent to their discharge from service. In many cases, these individuals receive compensation for these disabilities from the VA only. We also learned that the sum of the payments to all living veterans dating back to WWII is staggering. Not surprisingly, a significant portion of the disabilities compensated appeared to be related to musculoskeletal injury. Little research was being done. Full understanding of the nature and natural history of disability would ultimately require study of both DoD and VA data, and ideally a direct linkage of the two.

Between the Army and the VA, there were many potential sources of disability data available for exploration. We started with what we knew best and with what we had most immediate access to: the Army data--initially, the electronic records. While very robust for analysis, these records do not contain all the information useful for study. Hard-copy records generated by the Army during medical board processing of soldiers are archived in St Louis where it was impractical to review them, and, even more worrisome, we learned that these copies were actually being destroyed to save space for new files. We worried that a tremendous opportunity for thorough study of disability in the Army would be lost if those records could not be saved. We were able to obtain permission to acquire some of these records and begin digitizing them for direct review as well as possible text-mining in the future. We believed we would then be able to identify important health-related risk factors or patterns that might otherwise be missed. In collaboration with the Army, we helped build infrastructure for the focused study of disability. Later, the Army obtained necessary resources to complete the scanning themselves and are just finishing this process. We believe those data will provide important information for understanding how disability occurs.

In addition to these text records, we were also provided access to electronic data (more summarized information in an electronic format, which is easier to use for analysis purposes) that included details on the type of disability, type of compensation award received, and whether or not the disability was considered combat-related. As we did this early work, we were astounded to learn about how much money was being spent on disability or disability-related care. While this is not an exact-enough estimate to quote me directly, the amount the VA spends per year on disability runs in the neighborhood of $50 billion (about equally split between direct medical care and direct personal compensation payments). With all the money that was already being spent on disability we were even more surprised when our data revealed that the disability rate has been increasing fairly steadily for more than a decade, and musculoskeletal disability was increasing the fastest.

The policies and procedures for assessing disability and then receiving a compensation package are complex and a topic of great national debate. The recent problems at Walter Reed (Army Medical Center) and complaints from veterans have drawn even more attention to the disability problem. I just read this morning that beginning in 2008 the military disability system will have to align more closely with the VA system for rating disability. In the past, the active military side of disability evaluations usually resulted in a less favorable rating than that which the soldier typically received at the VA (particularly for conditions such as mental health disorders). The main reason for that was ostensibly because the military was concerned more about a service member's ability to serve and the VA was more concerned about functional limitations in general. There are other remaining challenges that face veterans trying to navigate their way through a confusing morass of policies and benefits outcomes. There has been a long-standing principle that no one should be able to receive concurrent retirement benefits and disability benefits based upon the same service. However, because retirement pay was offset 1 for 1 with disability compensation, the net effect had been that individuals who retire healthy receive retirement pay and can gain unfettered civilian employment while those with disability who can't work receive only retirement benefits. Military and veterans' advocacy groups have tried for many years to have that inequity rescinded. Starting with the Defense Authorization Act of 2004, concurrent receipt restrictions for certain veterans have been removed. A series of bills approved since, or which are currently under debate, aim to further reduce restrictions. While this may be a good and just occurrence for our veterans, it is going to increase the already substantial cost of military service-connected disability to the U.S. taxpayer significantly. As we learned more about these issues, we became more intrigued by the problem of disability. We realized that very little had been done to document the extent of the problem of disability and to describe risk factors. We believe that to reduce the burden of disability we have to begin by describing the extent of the problem and then looking back in time at the natural history or exposures and risk factors that occurred earlier in the military career. We put together a grant proposal with this goal in mind and submitted it in the Spring of 2005. It was funded, and we began work on it during the Summer of 2006. The paper you are featuring was the first product from that grant-funded effort.

EP: Has the Army had the opportunity to assess and respond in any way yet to your research findings?

NB: The Total Army Injury and Health Outcomes Database (TAIHOD) that we use is housed at the U.S. Army Research Institute of Environmental Medicine (USARIEM) in Natick, Massachusetts. I should mention that because of privacy concerns and protection of human subjects data, all work is done by Social Sectors Development Strategies, Inc. (SSDS) staff located on the base, using files that have all personal identifiers removed. The military department chair responsible for the oversight and protection of the TAIHOD data, Dr. Edward Zambraski (Chief, Military Performance Division), has been very supportive of our work, as has the USARIEM Commander. USARIEM was provided an advance copy of the manuscript and had no objection to its content. They have asked that we help them put together a summary of key findings that they can use in their briefings to help raise awareness of the problem of disability. The Madigan Army Medical Center also reviewed the manuscript since one of the co-authors is on staff there.

To the best of our knowledge, no one else has had a chance to review and respond to the findings.

EP: What outcomes does your team hope might be achieved by an assessment of your findings and any subsequent implementation of new plans?

NB: Ultimately, I hope that the information will be useful in both focusing more attention on the sheer magnitude of the disability problem AND in developing targeted intervention programs. The ultimate goal is to find a way to reduce the burden of disability and to improve health outcomes and quality of life (and in the process reduce the amount of money needed for disability-related care and compensation benefits).

EP: While your group is merely reporting its findings, do you have any concern that this data, which includes the monetary cost of disability in both the civilian and military populations, will promote a backlash of sorts in people's perceptions about funding and other resources being spent on disabilities?

NB: I hope that it does shock people. I believe people ought to know how much is being spent on problems that may be preventable (at least in part). Ideally, I hope it motivates us as a society to take steps to reduce the burden of disability simply because it is the right thing to do. While we are pleased to have received funding to pursue this research, the magnitude of the resources devoted to the study of disability are still inadequate given the magnitude of the problem (in this researcher's opinion). So we certainly hope that increased awareness will result in more study. The men and women who serve in the Armed Forces are doing a service for their country and ought to know that steps will be taken to mitigate their injury and disability risks. But, sometimes idealism is a less potent motivator than the desire to reduce costs. So, if wanting to reduce the burden of disability is not motivation enough, I hope that wanting to reduce the enormous costs associated with caring for and compensating those who are disabled will provide sufficient motivation to seek ways to lower the risk of injury or other exposures that ultimately cause or contribute to disability.

EP: Given that females in the military constitute one of the groups among which disability is increasing most rapidly, do you think that these findings could inadvertently lend support to those who argue that women should not be serving?

NB: It would not be particularly useful to eliminate or restrict any particular demographic group at greater risk for one health outcome (in this case disability) from the Army. The disability increases are largely occurring within one particular category of disability: musculoskeletal disorders. While musculoskeletal disability is the fastest growing category of disability and women are at greater risk than men for this type of disability, the fact remains that the vast majority (approximately 85 percent) of soldiers are men and a sizable proportion of them will experience musculoskeletal disability. It's also important to note that the risk for musculoskeletal disability is also increasing among the male soldiers, just not as rapidly as the rates are increasing among female soldiers. So, even if there were no women in the military, there would still be a lot of men experiencing these conditions. In addition, even though women were at greater risk for musculoskeletal disorders than men, other research we are working on suggests that men are at greater risk (relative to women) for certain other types of disability outcomes. There are also other health conditions for which women's risks are lower than men's risks. In sum, it makes more sense to focus on underlying causal factors rather than eliminating one particular demographic group from the risk pool.

EP: Which study does the group anticipate will be published next?

NB:: Our next paper has just undergone peer review, and we are in the process of revising it based upon peer feedback. It focuses on differences in risk factors for different types or causes of disability and variation in compensation packages. The paper that has just been published and this second one that we are revising both address the need for baseline documentation of the extent of the problem of disability. Remaining papers focus on trying to uncover important modifiable risk factors that can then be used to inform intervention strategies.

We have started on an analysis of risk factors for mental health disorders and will soon begin a study that focuses just on musculoskeletal disability. We are nearing completion on a report that explores occupational exposures, such as heavy physical demands, and injury and disability risk. In the out years of our study, we will take a closer look at the influence of pre-existing conditions and on combat-related disability. As important as these early papers are, we are just scratching the surface.

EP will continue to follow the results of the studies being conducted by the research group.

A complete copy of the study, The Changing Profile of Disability in the U.S. Army, can be found in the Disability and Health Journal (http://www.disabilityandhealthjnl.com), Volume 1, Issue 1, Pages 14-24, at http://download.journals.elsevierhealth.com/pdfs/journals /1936-6574/PIIS193665740700009X.pdf.

Authors of the study include Nicole S. Bell, ScD, MPH; Carolyn E. Schwartz, ScD; Thomas Harford, PhD; Ilyssa E. Hollander, MPH; and Paul J. Amoroso, MD, MPH.

Dr. Nicole S. Bell, is a member of the Board of Directors and Vice President of Social Sectors Development Strategies, Inc. (SSDS). She is an adjunct assistant professor in the Department of Social and Behavioral Sciences at Boston University School of Public Health and is an affiliated faculty member at the Harvard Injury Control Research Center at Harvard University School of Public Health. Dr. Bell's husband, Dr. Paul Amoroso, also a member of the research group, is a colonel on active duty in the U.S. Army, and was deployed to Iraq in 2003.