A Process to Identify Military Injury Prevention Priorities Based on Injury Type and Limited Duty Days

Background

Injuries, one of the leading public health problems in an otherwise healthy military population, affect operational readiness, increase healthcare costs, and result in disabilities and fatalities. This paper describes a systematic, data-driven, injury prevention–decision making process to rank potential injury prevention targets.

Methods

Medical surveillance and safety report data on injuries for 2004 were reviewed. Nonfatal injury diagnoses (ICD-9-CM codes) obtained from the Defense Medical Surveillance System were ranked according to incident visit frequency and estimated limited duty days. Data on the top five injury types resulting in the greatest estimated limited duty days were matched with hospitalization and Service Safety Centers' accident investigation data to identify leading causes. Experts scored and ranked the causes using predetermined criteria that considered the importance of the problem, preventability, feasibility, timeliness of intervention establishment/results, and ability to evaluate. Department of Defense (DoD) and Service-specific injury prevention priorities were identified.

Results

Unintentional injuries lead all other medical conditions for number of medical encounters, individuals affected, and hospital bed days. The top ten injuries resulted in an estimated 25 million days of limited duty. Injury-related musculoskeletal conditions were a leading contributor to days of limited duty. Sports and physical training were the leading cause, followed by falls.

Conclusions

A systematic approach to injury prevention–decision making supports the DoD's goal of ensuring a healthy, fit force. The methodology described here advances this capability. Immediate follow-up efforts should employ both medical and safety data sets to identify and monitor injury prevention priorities.

Introduction

The past decade has witnessed growing recognition1, 2 that injuries are a leading cause of morbidity and mortality for the U.S. military, eroding combat readiness more than any other single disease or health condition in this generally healthy and physically active population, which is relatively free of competing causes of death and severe illness. In 2004, injuries accounted for more service member hospital bed days than any other category of diagnoses.³ Further, in three measures of the burden of injuries and diseases for the U.S. Department of Defense (DoD)—number of medical encounters, individuals affected, and hospital bed days—injuries led all diseases and other medical conditions (Figure 1).³

Medical and safety data have revealed that, across all Services (army, navy, Marine Corps, air force), unintentional (accidental) injuries caused 47%–57% of all deaths; 22%–63% of all disabilities; and 22%–31% of all hospitalizations.4, 5, 6 Further, service member injuries cost hundreds of millions of dollars annually, consuming the Services' resources (ALTARUM Institute. Economic analysis of information management requirements: injury cause coding. 2006, unpublished). The thousands of person-years of limited duty time due to injuries reduces military operational effectiveness. To address the magnitude of the injury problem in the U.S. military, in 2003 the Secretary of Defense mandated that rates of unintentional accidents and injuries must be markedly reduced¹ and established the Defense Safety Oversight Council (DSOC) to provide governance over DoD efforts to reduce preventable mishaps.

Subsequently, the DSOC requested the establishment of the DoD Military Injury Prevention Priorities Working Group (DMIPPWG) to develop a systematic, coordinated approach to injury prevention similar to the public health approach, in which surveillance is used to determine the existence and magnitude of the problem, and research or research-like analyses are used to systematically identify modifiable causes, risk factors, and effective prevention strategies.7, 8, 9, 10

Given the DSOC's interest in preventing injuries resulting in the greatest limited duty time, the prioritization process employed by the DMIPPWG focused on (1) identifying the frequency of injury types from available medical surveillance data; (2) estimating limited duty days by injury type; (3) identifying causes of the injury types resulting in the greatest limited duty time using existing medical and safety data sources; and (4) prioritizing these causes using predefined criteria that required evaluation of a range of factors that are known to influence prevention program and policy success. This prioritization process expands on a prior approach, which measured the magnitude of the injury burden using routinely collected causes of injury hospitalization available from medical surveillance data.¹¹ The purpose of this paper is to describe the working group's process and data used in the process, and to present the final results that were provided to the DSOC, which included a list of injury program and policy priorities by Service and recommendations for next steps.