Chronic multisymptom illness (CMI), a multisystem disorder characterized by chronic medically unexplained symptoms that lead to a loss of normal function, is associated with military deployment.1–9 Reports from the 1991 Gulf War were the first to suggest a 2-fold higher prevalence of CMI among deployed (29%) compared with nondeployed (16%) US Veterans2 and CMI was observed for Gulf War-deployed military from Denmark, Britain, and Canada.3,7,8,10,11 Recently, the Institute of Medicine (IOM) stated that “preliminary data suggest that CMI is occurring in Veterans of the Iraq and Afghanistan wars.”12 For example, in one report 57% of Veterans who returned from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND) screened positive for CMI13; however detailed studies of CMI among Veterans of these recent conflicts are sparse.
Currently the Veterans Health Administration (VHA) has a working definition for CMI, which includes but is not limited to chronic fatigue syndrome (CFS), fibromyalgia (FM), and irritable bowel syndrome (IBS).14 CFS, FM, and IBS, are each defined by a specific constellation of medically unexplained symptoms.2,5 Disabling fatigue is the primary symptom of CFS, but other symptoms are part of the case definition.6 FM is defined by widespread chronic musculoskeletal pain.15 IBS includes symptoms of the gastrointestinal system such as abdominal pain and altered bowel habits. Unlike CMI, the International Classification of Disease-9th edition-Clinical Modification (ICD-9-CM) has unique diagnosis codes for CFS, FM, and IBS. The prevalence of these conditions among US civilians is estimated to be 0.5–2% for CFS,16–18 2–8% for FM,15,18,19 and 7–15% for IBS.20,21 The prevalence among 1991 Gulf War deployed Veterans is estimated to be 1–10% for CFS,1,2,5,7,18,22,23 2–19% for FM,1,2,18,23 and 2–19% for IBS.5,18 Except for a couple of studies,24,25 these conditions have not been thoroughly examined among OEF/OIF/OND Veterans.
Risk of CFS, FM, and IBS is higher in females compared with males in studies of US civilians21,26–28 and the prevalence of CMI is higher in female compared with male Veterans deployed to the 1991 Gulf War.2,4 Also, CMI and related conditions of CFS, FM, and IBS are associated with post-traumatic stress disorder (PTSD)13,24,29–31 and depression2,21,26–28 and there is some evidence to support PTSD as a partial mediator of the trauma-CMI link.29,32
The unique characteristics of OEF/OIF/OND Veterans warrant new investigations of CMI. Female Veterans are the fastest growing subset of VHA users33 and make up 11% of OEF/OIF/OND compared with 7% of 1991 Gulf War Veterans.12 Also, PTSD is among the top 3 conditions reported by OEF/OIF/OND Veterans,12,34 with a prevalence of 18–68%, higher than the prevalence (2–12%) among 1991 Gulf War deployed Veterans.1,3,35 Also, compared with the Gulf War, OEF/OIF/OND deployments were longer and multiple deployments were more common.12 These characteristics indicate a particular need to understand CMI among females deployed to Iraq and Afghanistan.
The prevalence of CFS, FM, and IBS and related sociodemographic, mental health, and military service characteristics of female OEF/OIF/OND Veterans and other CMI-related diagnoses are unknown. Also, VHA outpatient settings of CMI-related diagnoses have not been described. Understanding the settings of CMI-related diagnoses for female Veterans, which may include VHA clinics dedicated to women’s health, may help to target resources to support the identification, management, and coordination of CMI-related care.
Our aims are (1) to estimate the prevalence of ICD-9-CM coded CMI-related diagnoses among female OEF/OIF/OND Veterans; (2) to describe sociodemographic, military, and mental health characteristics of Veterans with and without CMI-related diagnoses; and (3) to characterize the VHA outpatient settings of CMI-related diagnoses. We hypothesize that the prevalence of CMI-related diagnoses, CFS, FM, and IBS is higher among female OEF/OIF/OND deployed Veterans compared with the prevalence of CMI-related diagnoses among the totality of female, deployed, and non-deployed, Veterans currently accessing VHA. A better understanding of CMI-related diagnoses in female Veterans who access VHA may improve the identification of females at risk for CMI, advance prevention and management strategies, and inform policy.
Setting and Ethics
Female Veterans were identified from the national OEF/OIF/OND Roster (Roster) file that is provided to Veterans Affairs (VA) Central Office Environmental Epidemiology Service by the Defense Manpower Data Center. Veterans included in the Roster are a subset of military discharges identified as having enrolled in VHA. Roster data files were merged with data from the VA Informatics Computing Infrastructure (VINCI).36 These data included basic demographic files, clinical data, and all national inpatient and outpatient services provided to VHA users. All available data in VINCI were accessed for analysis of Veterans included in the Roster. The University of Utah Institutional Review Board and the VA Salt Lake City Health Care System Research and Development Committee approved the protocol for this study.
The OEF/OIF/OND Roster included 101,105 female Veterans as of December 2011. Of these we excluded 469 females with a history of a CMI-related diagnosis recorded in any VHA outpatient visit before their last deployment end date. This included those with multiple deployments and eligibility for VHA services in between those deployments. In addition, we excluded 22,201 females who did not access VHA after their last deployment end date over Fiscal Years (FY) 2002–2012. Our study population consisted of 78,435 female OEF/OIF/OND Veterans.
Veterans Currently Accessing VHA
We used the Voogo-0.1.23-SNAPSHOT search engine developed by the VINCI NLP Research Team to estimate the prevalence of CMI-related diagnoses among 2,450,356 females (who were deployed and nondeployed Veterans) currently accessing VHA as of November 2014.
We defined CMI-related diagnoses to include ICD-9-CM codes for CFS (780.71), FM (729.1), or IBS (564.1).25,37,38
We examined sociodemographic characteristics including age, race, marital status, and education. We reported age on date of first VHA visit since last deployment end date. We also examined factors related to Veterans’ military service component (active vs. reserve), rank, and branch of service. We examined mental health diagnoses of PTSD and depression, categorized using ICD-9-CM diagnostic codes 296.2-311.0, corresponding to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision39 and associated with VHA outpatient encounters.
Clinical Setting of CMI Diagnosis
We presented the top VHA clinical settings of first CMI-related diagnosis. The type of clinical setting was determined by groupings of “stop codes,” which are administrative identifiers for VHA clinics
We used the Z-test for 2 proportions to test the hypothesis that the proportion of females with CMI-related diagnoses was higher among OEF/OIF/OND Veterans compared to the proportion of CMI-related diagnoses among the totality of female Veterans currently accessing VHA.
We examined differences among female Veterans with and without CMI-related diagnoses including differences in frequency distributions of sociodemographic, military service, and mental health characteristics. We used the Pearson χ2 test to examine statistically significant differences in the distribution of these characteristics.
All P-values were 2-sided and defined to be significant at P<0.01. All analyses were conducted using Stata software (version 12.1 StataCorp, 2011).
The Prevalence of CMI-related Diagnoses
Among 78,435 OEF/OIF/OND female Veterans who accessed VHA from FY2002–2012 after their last deployment end date, there were 6397 (8.2%) who had one or more reported CMI-related diagnosis after their last deployment end date (Table 1). Over the 10-year observation period there were 301 (0.4%); 3984 (5.1%); and 2716 (3.5%) females diagnosed with CFS, FM, and IBS, respectively. There were 604 (0.8%) female Veterans with 2 or more CMI-related diagnoses.
The prevalence of CMI-related diagnoses among female OEF/OIF/OND Veterans was over twice as high as the prevalence 95,424 (3.9%) among the totality of female Veterans currently accessing VHA (P<0.01) (Table S1, Supplemental Digital Content 1,. http://links.lww.com/MLR/A855).
Characteristics of OEF/OIF/OND Veterans With and Without CMI-related Diagnoses
Compared with Veterans without CMI-related diagnoses, Veterans with CMI-related diagnoses were older, and had a higher proportion of married Veterans, Veterans with more than high school education, active duty Veterans, enlisted Veterans, and Veterans who served with the Army or Air Force (Table 2). Differences across age, marital status, education, military component, rank, and branch of service were statistically significant (P<0.01) across CMI-related diagnosis status. Also statistically significant were the differences in PTSD and depression prevalence across CMI-related diagnosis status. Female Veterans with CMI-related diagnoses were at least twice as likely to have a diagnosis of PTSD or depression compared with female Veterans without CMI-related diagnoses.
VHA Outpatient Settings of First CMI-related Diagnoses
First CMI-related diagnoses were predominantly made in primary care, women’s health, neurology (especially for diagnoses of CFS), physical medicine and rehabilitation clinics (especially for diagnoses of FM), gastrointestinal clinics (especially for diagnoses of IBS), and other outpatient settings in VHA facilities across the country (Table 3).
To the best of our knowledge this is the first detailed description of new CMI-related diagnoses among female OEF/OIF/OND Veterans nationwide. Consistent with our hypothesis, the prevalence of CMI-related diagnoses among female OEF/OIF/OND Veterans was higher compared with the prevalence of CMI-related diagnoses among the totality of female Veterans currently accessing VHA. Also, we found several differences in sociodemographic, military, and mental health characteristics across females with and without CMI-related diagnoses.
The Prevalence of CMI-related Diagnoses
We are not aware of other studies among OEF/OIF/OND Veterans that report the prevalence of CFS or FM. There is 1 study by Maguen et al24 that reports a prevalence of IBS (by ICD-9-CM) of 3.7% among female compared with 1.6% among male OEF/OIF/OND Veterans. Consistent with Maguen and colleagues we estimated a prevalence of IBS of 3.5% among female OEF/OIF/OND Veterans.
To date, we are only aware of 1 study by McAndrew et al13 of CMI (not limited to CFS, FM, and IBS) among OEF/OIF/OND Veterans. The HEROS Study is a prospective longitudinal study of National Guard and Reserve Army enlisted personnel. CMI was assessed prospectively using the definition described by Fukuda et al4 One year after deployment, 57.2% of the 335 study participants screened positive for CMI.13 This suggests that the current analysis of CMI-related diagnoses, prevalent among 8.2% of OEF/OIF/OND female Veterans underestimates the true prevalence of CMI. We sought to explore this further by examining ICD-9-CM coded symptoms that may be related to CMI or part of its more comprehensive definition.
For example, the IOM report on Gulf War and Health: Treatment for Chronic Multisymptom Illness noted that CMI-related symptoms may include malaise, fatigue, other and unspecified episodic mood disorders, signs and symptoms involving cognition, nervous, musculoskeletal, cardiovascular, digestive, respiratory, and other chest symptoms,40 many of these are included in the CMI definition described by Fukuda et al4 and are part of VHA’s current working definition of CMI.14 We also note that these symptoms were prevalent among 59.2% of female OEF/OIF/OND Veterans with CMI-related diagnoses (Table S2, Supplemental Digital Content 2, http://links.lww.com/MLR/A856). Among female OEF/OIF/OND Veterans 18,787 (24.0%) were without a CMI-related diagnosis and had one or more of the above IOM report listed CMI-related symptoms (Table S3, Supplemental Digital Content 3, http://links.lww.com/MLR/A857). Thus, the overall prevalence of ICD-9-CM coded CMI-related diagnoses and symptoms was 32.2% in the current study of female OEF/OIF/OND Veterans, still lower than that suggested by the prospective study by McAndrew and colleagues whether the difference in estimated prevalence can be explained by the case definition/ascertainment of CMI, study design (ie, prospective screening vs. retrospective cross-sectional analysis of ICD-9-CM codes), or differences in study population requires further examination.
Since previous studies have supported associations of deployment, PTSD, and depression with CMI, we expected the prevalence of CMI-related diagnoses to be higher among female OEF/OIF/OND Veterans compared with the prevalence among the totality of female (deployed and nondeployed) Veterans currently accessing VHA. Our hypothesis was supported by our crude comparison and suggested that CMI-related diagnoses were at least twice as prevalent among female OEF/OIF/OND Veterans. Also, we confirmed that the prevalence of PTSD (4.0%) and depression (5.9%) was lower among female Veterans currently accessing VHA compared with female OEF/OIF/OND Veterans (PTSD prevalence: 29.2%, depression prevalence: 21.4%). We note that our comparison did not account for characteristics including age, race, number of deployments, predeployment stressful events or other variables that may be associated with OEF/OIF/OND deployment and CMI. Future studies that adjust/account for these and other potential confounding or mediating variables are needed.
Characteristics of OEF/OIF/OND Veterans With and Without CMI-related Diagnoses
Our study is consistent with others that suggest that older age and mental health diagnoses of PTSD and depression are associated with CMI-related diagnoses.2,14,37,41 Frayne et al42 demonstrated that among female Veterans, across all age strata, these mental health diagnoses co-occur, are related to excess morbidity including chronic pain, and functional status limitations. Also, among OEF/OIF Veterans with PTSD, results suggested that the burden of medical illness was greater in females compared with males.43 The authors emphasize the necessity of identifying, providing services and care coordination for prevalent conditions of PTSD and depression in females, such as CMI-related diagnoses as identified in the current study.42
Other characteristics that may be associated with CMI-related diagnoses including marital status, education, and military characteristics have not been examined. Future studies may seek to replicate our findings and examine whether these characteristics are independently associated with CMI-related diagnoses.
VHA Outpatient Settings of First CMI-related Diagnoses
Most CMI-related diagnoses among female OEF/OIF/OND Veterans were in VHA primary care and women’s health settings. Physical medicine and rehabilitation clinics also accounted for many of the FM diagnoses. Since most CMI-related diagnoses occur within primary or women’s primary care it may be important to ensure that these settings are well equipped with the latest evidence-based practice guidelines for identifying and managing CMI-related diagnoses and that procedures are in place for timely referrals to specialists, especially if a diagnosis is inconclusive.44 We note that while some have raised concern that patients in the general population may be uncomfortable with receiving diagnoses related to CMI or that such a label may hinder efforts to improve their health, others have argued that overall, a correct diagnosis is beneficial to a patient in helping them to focus on treatment and resolving anxieties of an unknown diagnosis.19 Studies also support that receiving a diagnosis related to CMI is associated with a reduction in unnecessary health care utilization including fewer diagnostic tests, referrals, and inappropriate treatment.45
Study Strengths and Limitations
While a distinct strength of our study is the nationwide scope and 10-year observation period of all female OEF/OIF/OND Veterans who used VHA, we acknowledge several limitations. We restricted our analysis of CMI-related diagnoses to assigned ICD-9-CM codes for diagnoses of CFS, FM, and IBS (specific subtypes of CMI). However, many Veterans (24.0%) were estimated to have symptoms that may suggest CMI presentation, but did not have a diagnosis of CFS, FM, or IBS. Diagnoses based on ICD-9-CM codes are vulnerable to misclassification and factors have been identified that lead to systematic underreporting of ICD-9-CM codes including documentation training of providers, a limited number of codes assigned in the outpatient setting, and VHA rules that may influence code assignment.46,47 The clinic setting of CMI-related diagnoses made may add validity to the diagnosis (eg, gastrointestinal vs. primary care clinic for IBS). We note that usual practice is to have a preidentified set of commonly used codes in clinic. If the code for the condition is not in the commonly used set and/or takes significant effort to find, the code is less likely to be assigned by the treating provider. Since Veterans may seek care outside the VHA and may not obtain a CMI-related diagnosis within VHA, we restricted our analyses to Veterans who accessed VHA at least once after their last deployment end date. Therefore, the prevalence of CMI-related diagnoses may be under or overestimated among female OEF/OIF/OND Veterans over the 10-year period. Also, Veterans who access VHA may not generalize to all separated OEF/OIF/OND Veterans. We were unable to examine incidence of CMI-related diagnoses since we did not screen Veterans for history of CMI-related diagnoses at their last deployment end date. Although we did attempt to exclude Veterans with a history of CMI-related diagnoses if it was noted in their VHA medical records before their last deployment end date. Last, we did not examine chronicity (eg, diagnoses/symptoms lasting at least 6 mo) of CMI-related diagnoses or symptoms.
This represents an important first look at CMI diagnoses in female Veterans who use VHA but there is a need to pursue this line of research with more in-depth studies. Evaluating the models of care and health care utilization related to CMI in female Veterans will provide further insight into how their health is being managed in VHA facilities and areas for improvement. Future research and operational goals should focus on improving screening and recognition of CMI and promoting best practices in the management of CMI. These and future findings can inform VA and the Department of Defense policy regarding the care of female Veterans with CMI.
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