| | The changing profile of disability in the U.S. Army: 1981-2005Abstract BackgroundWe 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. MethodsFrequency distributions and logistic regression analyses describe active-duty Army soldiers discharged with a disability (January 1981 through December 2005; N = 108,119). Time-series analysis describes temporal changes in demographic factors associated with disability. ResultsDisability risk has increased 7-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. ConclusionDisability 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. Disability is a large and growing problem in both military and civilian populations in the United States. Among working-age civilians, the rate of persons receiving benefits for a permanent disability rose approximately 40% between 1990 and 1999 [1]. The costs of occupational disability among civilian populations in the United States in 1997 were estimated at approximately $182.6 billion. Moreover, per capita medical expenses for adults aged 18 or older were 5 times greater for the disabled than for the nondisabled population [2]. Public benefits for all disabled beneficiaries in the United States amounted to almost $76 billion in 2005 [3]. The economic costs of disability to the U.S. military and the Department of Veterans Affairs (VA) are staggering. In fiscal year 2005, the Department of Defense (DoD) paid disability-retired military service members $1.25 billion, $474 million of which was for disabled Army retirees [4]. The VA made estimated disability payments of $29 billion in 2005 [5], [6]. While total medical care costs for disabled Army soldiers are unknown, VA facility treatment costs for Army soldiers with a medical discharge between 1986 and 1995 were estimated at approximately $124 million in 2001 alone and the cost of running the VA medical system is on the order of $25 billion annually, with most of this care rendered to disabled veterans [6], [7]. These costs are bound to increase dramatically once soldiers with disabilities related to Operation Iraqi Freedom are processed and enter the DoD and VA systems. Reductions in military occupational productivity prior to disablement, wage losses of disabled individuals and any caretakers, inability to perform household tasks, and decreased quality of life due to the disabling condition are not factored into the costs of disability [8], [9]. Recruitment and replacement training costs, as well as costs of losing experienced employees, are not estimated. Similarly, medical care for the condition prior to disablement and administrative costs associated with evaluating and processing disability are not well documented. Also hard to quantify are the costs associated with the Army's investment in training and maintaining soldiers whose careers are later cut short by a disability. Despite the large and growing problem of disability among military populations, relatively few studies have described occupational or demographic risk factors. Between 1981 and 2002, the number of active-duty Army personnel fell by 37% as part of an overall downsizing effort [10]. 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 [11], [12]; these factors may be associated with increased risk for subsequent disability. Although studies of disability among Army soldiers are limited, with most of the published studies focused primarily on a particular type of musculoskeletal condition (e.g., knee injury), there is some evidence suggesting that female soldiers are at greater risk for injuries, illnesses, and medical disability discharge than are men [13], [14], [15], [16]. Estimates of the excess risk of discharge for injuries among females compared with males in the military range from 2.5:1 [15] to 7.0:1 [14]. The authors postulate that lower levels of physical fitness and endurance [15], differences in strength, or ergonomic differences [14], as well as a greater likelihood of seeking medical care [17], may explain the gender differences. Age has also been associated with risk of occupational disability, but the direction of the association has been inconsistent in studies of Army populations and the few studies available focus only on musculoskeletal injury [16], [18]. The relationship between age and occupational disability may not be linear and probably interacts with gender or other factors [16]. Age may also be confounded by other factors such as rank and time in service, as older individuals are more likely to be in higher ranks and have longer service experience and consequently less likely to be in highly physically demanding jobs that cannot be performed with physical limitations [19], [20]. In assessing increasing trends in disability, it is important to clarify what proportion of these increases may be attributable to changes in the demographic characteristics of the U.S. Army population at large and what proportion of increased disability rates remains unexplained or requires greater investigation in order to uncover the etiology. At the same time as the risk of disability has increased, the demographic profile of active-duty soldiers has changed. From 1985 to 2005, the ratio of males to females in the Army declined [21] and the average age of soldiers increased [11]. It is important to separate the effects of demographic shifts from real changes in disability risk. Aims  The objectives of this descriptive study were to (1) document and describe the overall population of soldiers discharged from the Army with a permanent disability; (2) to determine whether temporal changes in the demographic composition of the Army population explain the increasing risk of disability discharge; and (3) to describe temporal changes in the demographic profile of those who are disabled in order to better inform interventions and future analytic work. Methods Data sources Data come from the Total Army Injury and Health Outcomes Database (TAIHOD), a compilation of files containing demographic and health information on active-duty Army personnel that can be linked through individual identifiers [22], [23], [24]. TAIHOD components used for this paper included the Defense Manpower Data Center (DMDC) personnel records, which provide demographic and discharge information and disability board records from the U.S. Army Physical Disability Agency. Sample The total sample of all active-duty Army soldiers discharged with permanent disability between January 1981 and December 2005 included in this analysis is 108,119 soldiers. Measures Disability outcome measure DoD Directive 1332.18 defines disability as “Separation from the Military Service by Reason of Physical Disability” (1996). The disability can be caused by, aggravated by, or even unrelated to military service. DoD 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 [25], [26]. Soldiers whose physical or mental health conditions make them unlikely to return to active duty despite having received optimal medical treatment for their condition are referred to a medical evaluation board (MEB). The MEB reviews all available medical and occupational evidence and may make a recommendation regarding the need for another disability evaluation, which is performed by the physical evaluation board (PEB). Following PEB evaluation, if a determination of unfitness is made, the PEB further determines if the condition is stable (no further improvement expected). Stable conditions are eligible for a permanent disability discharge. When the PEB evaluation finds that there is some potential for improvement in the condition, the soldier may be recommended for the Temporary Disability Retired List after which he or she will be reevaluated periodically over the ensuing 5 years to assess his or her ability to return to active duty [27]. Only confirmed permanent disabilities with a record of discharge from the Army were analyzed in this study. Type of disability The Army uses the Veterans Administration Schedule for Rating Disabilities (VASRD) to describe and rate disabilities (38 C.F.R. 4). Organized into 16 body/organ system groups, the VASRD describes functional limitations that can be used as the basis for a percentage of disability. Causes or major types of disability are defined in the 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. Demographic covariates Demographic covariates included gender, age, race, marital status, education, and time in service. Age is coded as less than 21 years, 21-25 years, 26-30 years, 31-35 years, 36-40 years and greater than 40 years; race is categorized as white, black, Hispanic, and other; marital status includes single (never-married), married, and previously married (i.e., widowed, divorced, or legally separated); education is coded as less than or equal to high school degree (or degree equivalent), some college, and completed college or above; rank was coded for enlisted personnel as Junior (E1-E4), Mid-level (E5-E6), and Senior (E7-E9) and for Officers as Warrant Officer (W1-W5), O1–O3, O4–O5, and O6–O11; and total time in service at time of discharge was coded as less than 1 year, 1+ to 2 years, 2+ to 3 years, 3+ to 4 years, 4+ to 5 years, 5+ to 7 years, 7+ to 10 years, 10+ to 15 years, and greater than 15 years. Data analysis Frequency distributions and odds ratios from bivariate logistic regression models were used initially to describe the demographic characteristics of soldiers discharged with a permanent disability. Risks for disability discharge were calculated by dividing the total number of active-duty soldiers discharged with a permanent disability by the total number of soldiers on active duty during that year based on DMDC personnel file data. A soldier on active duty at any time during a calendar year counted toward the annual denominator. To control for temporal shifts in discharge from the Army, we also examined risk of disability discharge just among soldiers who were discharged from the Army in a given year. Because trend lines were very similar when we used either total population or total discharges as the denominator, we only report findings using the total army population, instead of discharges, as the denominator with disability risks reported per 100,000 active-duty soldiers in that year. This allows for greater comparability with nonmilitary data. To assess the influence of temporal changes in the Army's demographic profile on the annual risk for disability, unadjusted risks for disability discharge were plotted alongside risks adjusted for temporal changes in gender, race, age, and time in service. Data were directly standardized to the 1981 Army population profile. Autoregressive time-series analytic models were also used to assess temporal changes in the demographic profile of soldiers discharged with a disability for the years 1981 through 2005. In time-series data, error terms may be serially correlated, yielding bias in ordinary regression models. Autoregressive models correct for the autocorrelation between data in a related series (i.e., years 1982 through 2005). Stepwise autocorrelation selects the order of the autoregressive error model (i.e., AR1, first-order autocorrelations that adjust for the prior 1 year; AR2, second-order autocorrelations that adjust for 2 years prior). The Durbin-Watson test is used to test for the presence of autocorrelation; when it is not significant, the model has effectively reduced the bias due to autocorrelation. The ARCHTEST disturbances (i.e., Q statistics test and Lagrange Multiplier test) are used to test for heteroscedasticity of error variance [28]. When these statistics are not significant, the error variance is considered homoscedastic. In separate analyses, rates of permanent disability per 100,000 population for specific demographic groups were regressed on years of study period (1981-2005). Log transformation was applied and temporal estimates from the autoregressive models are interpreted in terms of percent change by taking the exponent of the obtained estimate. Analyses were conducted using SAS versions 8.2 and 9 (SAS Institute, Cary, NC). All analyses for this project adhere to the policies for the protection of human subjects as prescribed in Army Regulation 70-25, and with the provisions of 45 C.F.R. 46. Results Between 1981 and 2005, 2,724,359 soldiers were discharged from the Army and, of these, about 4% left the Army with a documented permanent disability (N = 108,119). While the overall Army population has decreased from 922,448 in 1981 to 564,802 in 2005, the number of disability cases each year has actually increased from 1,641 in 1981 to 7,126 in 2005. The annual disability discharge risk per 100,000 population increased by over 600% between 1981 and 2005. Although there was some volatility in disability risk between individual years of the study period, the overall trend has been increasing, representing an average annual increase of nearly 10% per year over the past 25 years. In 1981, the risk of disability discharge was 178 per 100,000, but by 2005 the risk had climbed to 1,262 per 100,000 soldiers on active duty that year (data not shown). Table 1 describes the demographic characteristics of soldiers discharged with a permanent disability compared with those soldiers discharged from the military without a disability during the study period. Soldiers discharged with a permanent disability between 1981 and 2005 were more likely to be female, older than 21 but less than 40 years of age (31- to 35-year-olds were at greatest risk), married or previously married, mid-level or junior enlisted (as opposed to senior enlisted or officers), and significantly less likely to have a college education. | ∗ Excludes soldiers discharged with temporary disability from analysis. |
Over the 25-year study period, the overall demographic profile of the Army at large changed. There was a shift toward greater female representation (the proportion of female soldiers in the Army increased from 10% in 1981 to 15% by 2005). The proportions of white and black soldiers declined (63% to 61% and 29% to 22%, respectively), while the Hispanic population increased from 4% to 11% and “other” racial and ethnic groups (as a whole) increased from 4% to 7%. The proportion of officers in the Army increased from 10% to 13%, while the proportions of enlisted soldiers declined from 88% to 85%. The average age of the population also went up, most notably increasing among those aged 36 or older while younger age groups experienced a relative decrease. The average time in service of active-duty soldiers shifted toward a greater proportion of soldiers remaining on active duty past 10 years. Between 1981 and 2005 the proportion of soldiers on active duty for less than 2 years declined from 39% to 31%; those with 2 to 5 years or 6 to 10 years of total active service remained relatively stable (32% to 31% and 14% to 15%, respectively, between 1981 and 2005). Those with greater than 10 years of active service increased from 15% to 24% over the same time period. The percentage of soldiers with a college degree increased from 19% to 21%, although there was a great deal of temporal volatility with proportions of college-educated soldiers varying over the study period (data not shown). To assess the hypothesis that changes in the underlying Army population as a whole explain all or part of the increasing disability trends, the unadjusted disability risk per 100,000 population and disability risks adjusted for changes in gender, race, age, and total time on active duty were plotted side by side (Figure 1). The lack of an effect on the disability risk after standardization suggests that changes in underlying population characteristics do not explain the increasing risk of disability over the time period. In order to begin to understand the underlying etiology of the increasing risk for disability it is important to determine whether identified risk factors (see Table 1) are constant or whether they, too, are changing. That is, is the overall profile of disability changing in the Army? Figure 2, Figure 3, Figure 4, Figure 5, Figure 6 show changes in the risk of disability over time by key demographic subpopulations (gender, age, time in service, rank, and educational groups) and suggest that the profile of soldiers who experience disability has changed over the time period. Risk of disability discharge per 100,000 women and per 100,000 men are both trending up, but since about 1990, the risk of disability for female soldiers has been increasing at a faster pace than the risk for male soldiers (Figure 2). Significant changes in risk for disability by gender were tested in autoregressive time-series models (Table 2). Based on the gender specific risks of permanent disability shown in Figure 2, autoregressive models yielded statistically significant temporal patterns among female (p < .001) and male (p < .001) soldiers. Specifically, the rates for female soldiers increased by 8% with each successive year while the rates for male soldiers increased by 5% with each increasing year. Figure 3 depicts age-specific risks for disability. In the beginning of the study period, 21- to 30-year-olds were among those at lowest risk for disability. But by 1990 their risk had increased rapidly, surpassing all other age groups. In contrast, those over age 40 were initially at greatest risk, but by the late 1990s their risk of disability had dropped to the very bottom of the group (Figure 3). Autoregressive models yielded statistically significant temporal patterns for soldiers under the age of 36. Specifically, the disability risks for soldiers aged 35 and younger increased by 7% with each increasing year (p < .001). While the disability risks for soldiers aged 36 and older decreased by 1% with each increasing year, the temporal pattern was not statistically significant for soldiers 36 and older (see Table 2 and Figure 3). Thus, even though the Army at large is getting older and staying on active duty longer, soldiers discharged with a disability are getting younger. Figure 4 shows time in service. As with the age depictions in Figure 3, data indicate that risk for disability discharge among soldiers with the longest tenure declined while disability risks among soldiers with less than 10 years of active service increased. The increase has occurred most precipitously among soldiers with 2 to 5 years followed by 6 to 10 years of active service. The risk for permanent disability among soldiers with less than 2 years of service increased by 6% with each increasing year and the risks among soldiers with 2 to 10 years of service increased by 8% with each increasing year (p < .001) (see Table 2 and Figure 4). Figure 5 shows the association between rank and disability over the study period. The disability risks among officers and warrant officers were relatively stable until about 1998, at which point they began to climb. The risk of disability among enlisted soldiers was initially similar to officers, but during the late 1980s rates among lower ranking enlisted soldiers began to climb steeply and have continued to outpace the pattern of increased risk observed among officers, warrant officers, and higher-ranking enlisted soldiers. Autoregressive models indicate that the service-specific rate of permanent disability among commissioned and warrant officers increased by 2% for each increasing year (p < .05) (see Table 2). Among enlisted soldiers in grades E1 through E3, disability increased by 8% (p < .001), and the risk for permanent disability among enlisted soldiers in grades E4 and E5 increased by 4% for each increasing year (p < .001). In contrast, the risk of permanent disability among senior enlisted soldiers (E6 through E9) actually decreased by 3% with each increasing year (p < .02). College education appears to have an increasingly protective effect on disability over the study period (at least in analyses adjusted for education only, but not for other factors often associated with education) (Figure 6). Since about 1986, risk for disability among those without college education continued an upward trend started in 1981. But those with a college education actually experienced a drop in disability followed by a relatively long period of stability. In the late 1990s, the risk of disability among those with a college degree also began to rise, but it was still much lower than the risk among soldiers without a college degree. Autoregressive models yielded statistically significant temporal patterns based on education-specific risks for permanent disability (shown in Figure 6 and described in Table 2). Disability risk among soldiers with less than a college education increased by 6% with each increasing year (p < .001), while the risk among college-educated soldiers increased by only 4% with each increasing year (p < .01). In addition to changes in the demographic profile of soldiers experiencing disability, there have been changes in the nature of disability among high-risk subgroups. 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 (data not shown). While increases in musculoskeletal disabilities have been experienced by both male and female soldiers, the growing disability burden experienced by women appears to be primarily attributable to musculoskeletal disability (Figure 7). Similar patterns appear for the association between college education and disability and white race and disability. That is, the major type of disability driving the variation in risk between those with and those without a college education appears to be musculoskeletal disorder and the risk of musculoskeletal-related disability is increasing more rapidly among white soldiers, followed by black soldiers (data not shown). The pattern is only partially consistent for younger soldiers compared to soldiers over age 35. As with the other high-risk demographic subgroups, musculoskeletal disability risks are increasing for both age groups, but the risk for disability is increasing most rapidly for those aged 35 or less. The pattern differs for age comparisons regarding “other” causes of disability. For other high-risk demographic subgroups (women, non–college educated), there are relatively little differences in patterns of risk for nonmusculoskeletal disorders. In contrast, for those aged 35 or less, there is a notable increased risk for nonmusculoskeletal disorders while risk of nonmusculoskeletal disorder disability among those over age 35 is decreasing (data not shown). Discussion 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. Multiple factors may influence an individual's likelihood of disability discharge. While the primary influence is a medical condition inconsistent with productive service, a number of administrative, social, and Army cultural factors may also be important. For these reasons, changes in the risk for discharge with a disability must be interpreted with caution. Whether increases in disability discharges are directly related to an increase in injury and illness, earlier or more effective detection of these conditions by the Army medical system, a decrease in the Army's tolerance for retaining disabled individuals in the service, or an increase in individual propensity to seek evaluation or compensation cannot be directly determined from this preliminary review of the discharge data. In addition, the association between age and disability and tenure and disability should also be interpreted with caution as eligibility for disability benefits is partially dependent upon tenure. Soldiers with very short time on active duty (e.g., 2 years or less) may not be eligible for disability benefits and thus may not seek evaluation upon leaving the service with a disability. Thus, the real relationship between time in service (and, indirectly, age) and disability cannot be fully evaluated without placing it in the context of eligibility for benefits and, possibly, related motivation to seek disability evaluation upon discharge from the Army. Assessing the association between demographic risk factors and disability is complicated by changes in the overall Army demographic profile as well as by shifts in the disability risk profile over the study period. The underlying Army population demographics shifted toward greater proportions of female, older, and Hispanic soldiers and greater representation among officers with concurrent reductions in the relative proportions of enlisted soldiers. In addition, the overall size of the Army has dropped by nearly 40% over the study period. Shifts in the proportion of soldiers by rank suggest that much of this reduction has occurred within the enlisted ranks. Given the growing risk of disability among enlisted, particularly younger or junior enlisted, it is possible that military downsizing, concurrent with multiple deployments and other occupational stressors, may be contributing to the increasing risk for disability within this demographic subgroup. Enlisted soldiers comprise an occupational cohort that needs further study in order to fully evaluate the etiology of this increased risk for disability. Although the Army has become more female and disability risk is greater among female soldiers, adjusting for demographic changes, including greater representation of women and older soldiers with relatively fewer black, but more Hispanic, soldiers does not explain the increased risk for disability in the overall Army population. The lack of impact made by adjustment is due to the differences in the direction the adjustment shifts the risks. The overall percentage of women in the Army at large has increased and the disability risk among women per population of women has increased. In contrast, the average age of those with disability has decreased at the same time as the average age of the Army at large has increased. Similarly, disability risk among white soldiers has increased slightly as the relative proportion of white soldiers has slightly declined. More research is needed to understand the etiology of the shift in the profile of soldiers experiencing permanent disability. It is not clear, for example, why risks for particular categories or types of disability among high-risk demographic groups have changed. It is not clear why certain demographic subgroups, notably women, younger soldiers, enlisted soldiers, and less educated soldiers, have more rapidly escalating disability risks. The apparent protective effect of college education is worth further exploration. It is unclear whether this is related to a reduction in occupational exposures to certain risks, which might correspond to different job opportunities available to soldiers with a college degree, or whether it is more directly protective by improving resiliency or resistance to stress and/or improved self-care, which might result in reduced risk for long-term disability. In addition, because this is a descriptive study and results are not adjusted for other factors, the protective effect of a college education, higher rank, and, to some degree, older age is likely interrelated, making it difficult to parse out the unique contribution of the college degree alone. Those over the age of 35 have seen a dramatic decline in their risk for disability. In addition, soldiers who remain on active duty and who avoid serious injury or disease for 15 years appear likely to remain disability-free by the time they retire. This relative improvement in the health and well-being of older soldiers with longer tenure may reflect a healthy worker or “survivor” bias. Or, it could be due to changes in medical care and screening that have resulted in a reduced overall risk for cardiovascular diseases. Conclusion Little research has been published describing the soldiers who leave the U.S. Army with a permanent disability. Even less is known about the underlying causes of these disabilities. Yet, risk for disability is increasing rapidly, resulting in huge economic losses to the U.S. government and, ultimately, the taxpayer. In addition, and more importantly, 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 or through other health care 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 health care data longitudinally. To fully enumerate and understand disability morbidity, it will be necessary to examine disability compensation data from the Veterans Benefits Administration branch of the VA linked to Army discharge data. 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. Preliminary studies that have been able to link VA disability data, for Army soldiers who seek evaluation in the VA, with the Army disability data result in a 3-fold increase in disability case ascertainment (S. Sulsky, personal communication, 2007). There have been recent concerns over the actual treatment received by disabled veterans, the process for receipt of benefits and compensation, as well as various calls for improved data exchange between 2 agencies. Proposed changes in how disability is managed by the government may make it easier in the future to enumerate the total impact of disability [29], [30]. Results from these analyses suggest that changes in the underlying Army population demographics over time do not explain the overall increased risk in disability. While increases in disability risk are generally being experienced across all military demographic groups, the subgroups with the fastest growing risks are women and junior enlisted and younger soldiers. The primary cause of these disabilities appears to be injury or the adverse effects of acute and chronic injury and related musculoskeletal conditions. While more research is needed to understand the underlying causes of these conditions, the changing profile of disability suggests that key demographic groups to focus on include women, younger soldiers, junior- or mid-level enlisted soldiers, and those with less than a college education. Future research should include multivariate predictive models to assess the independent effect of gender, education, rank, and age, while controlling for changing temporal patterns (e.g., increasing risk among women over time, decreasing risk among older soldiers, increasing protective effect of college education) and accommodating potential interactions between risk factors (e.g., gender and age interactions) [16]. Future analyses should explore variations in risk factors for different types of disability overall and within high-risk subgroups. Models will need to control for variations in disability eligibility (e.g., time in service). Ultimately, results from this and future research efforts should be used to inform interventions with well-conceived evaluation plans in order to assess effectiveness in reducing the burden of disability. Acknowledgments This project was supported by a grant from the U.S. Army Medical Research and Material Command (grant No. W81XWH-06-2-0028). 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We can think of no conflicts of interest that might bias our work. The views expressed herein are those of the authors and do not necessarily reflect the views or official position of the Department of Defense or the U.S. Army. PII: S1936-6574(07)00009-X doi:10.1016/j.dhjo.2007.11.007 © 2008 Elsevier Inc. All rights reserved. | |
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