What are the new findings?

In 2023, injuries, mental health disorders, and musculoskeletal diseases constituted the categories of medical conditions associated with the most medical encounters, greatest numbers of members affected, as well as largest numbers of hospital days among active duty Coast Guard members, similar to DOD active component service members. Medical encounters increased by 13.3% when compared to last year, and major category conditions increased by 12.7% overall. In 2023 COVID-19 accounted for 0.4% of total medical encounters, a decrease from 1.4% in 2022, with no hospital bed days reported in 2023.

What is the impact on readiness and force health protection?

The major condition categories in this report present health challenges for members of the U.S. Coast Guard and affect their service readiness. Loss of duty availability related to illness and injury reduces Coast Guard personnel readiness. Coast Guard members have unique occupational exposures that may benefit from specific risk reduction programs to mitigate these threats.

Background

The U.S. Coast Guard is the second smallest service of the U.S. Armed Forces, comprised of approximately 40,000 active component service members, and the only military service operating outside the authority of the Department of Defense. Between 2016 and 2021, USCG health care data were excluded from MSMR’s annual morbidity burden reports due to missing data.^1,2 USCG personnel are eligible to use DOD health care facilities, but as many service members are not stationed near a DOD installation, the USCG operates primary care clinics in areas with sufficiently large Coast Guard populations. A higher proportion of civilian hospitalizations among USCG members has been noted,¹ and this difference may extend to ambulatory care as well.

To quantify the impacts of various illnesses and injuries among members of the active component of the USCG in 2023, this summary employs the same disease classification system and morbidity burden measures used in the general active component burden analysis.

Methods

The population for this analysis included all individuals who served in the active component of the USCG at any time during the surveillance period of January 1, 2023 through December 31, 2023. The methodology for summarizing absolute and relative USCG morbidity burdens in 2023 is identical to the methodology described on page 3 of this issue that was used to determine the absolute and relative burdens attributed to various illnesses and injuries among the active component of the U.S. Armed Forces.

Results

In 2023 a total of 37,438 USCG service members had 442,798 total medical encounters, which included 8,917 bed days reported, for a rate of 0.24 bed days per USCG member who experienced at least 1 medical encounter (either ambulatory or hospitalization).

Morbidity burden, by category

In 2023, more active component USCG members (n=16,210 individuals affected) experienced medical encounters for injury than any other morbidity-related category (Figure 1a). Ranking third in terms of hospital bed days, this morbidity category accounted for over one-fifth (22.4%) of all medical encounters (Figure 1b).

Mental health disorders accounted for more hospital bed days (n=4,903) than any other morbidity-related category, comprising over half (55.0%) of all hospital bed days and ranking fifth in terms of numbers of individuals affected (Figures 1a and 1b). Injury and mental health disorders combined accounted for over three-fifths (66.9%) of all hospital bed days and almost two-fifths (40.8%) of all medical encounters.

Maternal conditions, e.g., pregnancy complications and delivery, accounted for a relatively large proportion of all hospital bed days (n=1,202; 13.5%) but a much smaller proportion of total medical encounters (n=3,884; 0.9%) (Figures 1a and 1b). Maternal conditions were the most prevalent medical condition among female active component USCG members. Women comprised approximately one-sixth (16.0%) of the active duty USCG in 2023.

Medical encounters, by condition

In 2023, 5 disease-related conditions accounted for more than one-third (36.9%) of all illness- and injury-related medical encounters among active component USCG members: other back problems (includes lower back pain and other dorsalgia), arm/shoulder injuries, anxiety disorders, organic sleep disorders (e.g., obstructive sleep apnea, insomnia), and knee injuries (Figure 2). Moreover, the 10 conditions associated with the most medical encounters constituted more than half (58.0%) of all illness- and injury-related medical encounters.

The conditions in 2023 that accounted predominantly for medical encounters among active component USCG members were injuries, mental health disorders, and musculoskeletal diseases. Arm/shoulder (7.5%), knee (5.4%), foot/ankle (3.3%), and leg (2.6%) injuries contributed the most medical encounters (Figure 2 and Table). Anxiety (7.3%), mood (4.6%), adjustment (4.1%), and alcohol/substance abuse disorders (1.3%) were the four most frequent mental health disorder diagnoses. Other back problems (9.4%), all other musculoskeletal diseases (4.7%), and cervicalgia (2.2%) constituted the most medical encounters among musculoskeletal disorders. COVID-19 accounted for 0.4% of total medical encounters during 2023.

Individuals affected, by condition

The 10 categories of conditions that affected the most USCG members in 2023 were all other signs and symptoms, refraction/accommodation, other back problems, upper respiratory infections, all other musculoskeletal diseases, organic sleep disorders, anxiety, all other skin diseases, arm and shoulder conditions, and respiratory and chest issues. COVID-19 affected 1,380 USCG members and ranked thirty-third for the number of individuals affected, a considerable decrease in rank from seventh in 2022.

Hospital bed days, by condition

In 2023, substance abuse and mood disorders accounted for about two-fifths (41.3%) of all hospital bed days (Figure 3). Four mental health disorders (substance abuse, mood, anxiety, adjustment) and two maternal conditions (pregnancy complications and delivery) combined accounted for more than three-fifths (62.5%) of all hospital bed days (Table and Figure 3). About 12% of all hospital bed days were attributable to injuries and poisonings. There were no hospitalizations due to COVID-19 among active component USCG members in 2023 (Table).

Discussion

Health care utilization within the USCG was similar to the DOD when measured by total encounters and persons affected in 2023. The USCG rate was 11.8 encounters per person (442,798 / 37,438), compared to the DOD rate of 11.6 encounters per person (14,013,185/1,204,509). The USCG had a lower rate of hospitalization, however, with only 0.24 bed days per individual; the DOD reported 0.32 bed days per individual (390,181/1,204,509). 

Compared to 2022, USCG medical encounters increased by 13.3%, with major category conditions reported increasing by 12.7% overall, and individuals affected and hospital bed days (8.5% and 2.3%, respectively) both rising as well. Mental health disorders resulted in more hospital stays than any other morbidity-related category, and mental health-related medical encounters increased by 21.5% compared to the previous year.

These reported increases may be overestimates, as 2022 was the first year DMSS data were archived and analyzed in the Military Health System Information Platform, and during last year’s morbidity burden analysis completeness issues were identified for MHS GENESIS data being transferred to DMSS. Opportunities to address and resolve missing data issues that result from USCG hospitalizations in civilian facilities should be prioritized to accurately depict the true burden of disease in this population.

This report is consistent with the major findings of prior annual reports on morbidity burdens among active component U.S. service members. Injuries, mental health disorders, and musculoskeletal diseases were the categories of medical conditions associated with the most medical encounters, the largest numbers of affected service members, and the greatest numbers of hospital bed days. When examining ICD codes to the fourth digit character, USCG and DOD service members shared many disease-related conditions: other back problems within the musculoskeletal disease major diagnostic category; arm/shoulder and knee injuries within the injury major diagnostic category; anxiety disorders in the mental health disorder major diagnostic category; and organic sleep disorders within the neurologic condition major diagnostic category.

COVID-19 did not account significantly for medical encounters and bed days in 2023 compared to 2022. Besides the waning of the pandemic, active component service members represent a relatively young and healthy population less likely to experience severe consequences of COVID-19 infection.

Preventable illnesses and injuries, which contribute disproportionately to morbidity and health care burdens, should be high priority targets for intervention, research, and resources. In a 2018 survey, USCG members reported several mental health issues including serious psychological distress, failure to receive mental health services despite need, and other preventable risky health behaviors.³ Providing a matrix of major diseases each year enables the identification, in comparison with previous reports, of potentially avoidable health conditions among military personnel, and their proximate causes. Morbidity burden report findings can aid prioritization of effective interventions, provision of necessary care, and evaluation of their impacts and cost-effectiveness.⁴

References

1. Pillai S, Chau M, Kamara I, Thomas D, Iskander J. Hospitalizations among active duty members of the U.S. Coast Guard, fiscal year 2021. MSMR. 2023;30(2):3-5. 
2. Armed Forces Health Surveillance Branch. Hospitalizations among members of the active component, U.S. Armed Forces, 2015. MSMR. 2016;23(4):8-16. 
3. Pulkkinen AJ, My CG [Coast Guard]. Let’s talk about your behavioral health. United States Coast Guard, U.S. Department of Homeland Security. 2024. Accessed May 2, 2024. https://www.mycg.uscg.mil/News/Article/3671040/lets-talkabout-your-behavioral-health/ 
4. Devleesschauwer B, Maertens de Noordhout C, Smit GS, et al. Quantifying burden of disease to support public health policy in Belgium: opportunities and constraints. BMC Public Health. 2014;14:1196. doi:10.1186/1471-2458-14-1196 
5. World Health Organization. The Global Burden of Disease: 2004 Update. World Health Organization;2008. Accessed Jun. 4, 2024. https://www.who.int/publications/i/item/9789241563710 
6. Murray CJL, Lopez AD, eds. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Harvard University Press;1996:120-122.