Back to Top Skip to main content Skip to sub-navigation

Brief Report: Direct Care Cost of Heat Illness to the Army, 2016–2018

Thermometer (Photo credit: U.S. Army) Thermometer (Photo credit: U.S. Army)

Recommended Content:

Medical Surveillance Monthly Report

BACKGROUND

Heat injury surveillance in the Department of Defense (DoD) includes the more severe conditions, heat exhaustion and heat stroke.1 Hospitalization occurs more frequently among service members experiencing heat stroke; however, both conditions can result in hospitalization and may require follow-up medical care. Between 2014 and 2018, annual rates of heat illness have increased among U.S. active component members.This report describes the total direct medical cost to the Army associated with heat exhaustion and heat stroke from 2016 through 2018.

METHODS

The Weather-Related Injury Repository (WRIR) contains clinical data and medical event reports for heat and cold weather injuries in Army soldiers.3 The WRIR health encounter and admission data used in this analysis were derived from DoD military medical treatment facility medical records and paid TRICARE claims for beneficiaries at civilian facilities. Heat illness was identified using International Classification of Diseases, 10th Revision (ICD-10) codes for heat stroke (T67.0*) and heat exhaustion (T67.3*, T67.4*, T67.5*) in the primary or secondary diagnostic code positions.1For the purposes of this study, heat illness hospital admissions and outpatient encounters from 1 January 2016 through 31 December 2018 were extracted from the WRIR for Army active component and active and inactive National Guard and Reserve soldiers. Demographic characteristics were assigned according to the first encounter or admission during the analysis timeframe for each soldier.

Direct medical costs from the medical record and claims files were used to represent the cost of care paid for by the Military Health System (MHS). Variables for these costs have been included in the WRIR for each encounter since its implementation. For inpatient admissions to facilities owned and operated by the military, the direct cost of the care is captured in a variable identified as “full cost,” which includes the cost of clinician salary, ancillary laboratory and radiology, ancillary salary, and intensive and surgical care units. For outpatient visits associated with these facilities, the direct cost of care captured in the same full cost variable includes clinician salary, professional salary, laboratory, radiology, pharmacy, ancillary, support, and other costs. For contracted care provided in civilian or network facilities, the direct medical cost represents the amount paid by TRICARE. This variable, tracked in the patient’s medical record, has been used to estimate the total cost of each medical encounter in other reports evaluating medical costs for soldiers in the MHS.4–6

To determine the total direct medical cost, all hospital admission and outpatient encounter records with a heat exhaustion or heat stroke diagnosis meeting inclusion criteria were examined and the full cost and/or total amount paid for each heat illness encounter were summed by soldier and the date of care. Total direct medical care cost includes the cost of care associated with follow-up visits. The heat illness type was assigned based on the ICD-10 code in the primary or secondary position. The record was designated a heat stroke when either of the fields had a heat stroke diagnosis. Data were reported by clinical setting (outpatient and inpatient) and by heat illness type (heat exhaustion and heat stroke).

RESULTS

During the study period, 5,291 soldiers—1,027 (19.4%) females and 4,264 (80.6%) males—had 1 or more clinical records associated with heat stroke or heat exhaustion events (Table 1). The majority were enlisted soldiers (88.1%) and younger than 35 years old (90.8%). Of the soldiers who received care for a heat illness, 1 in 4 were members of the National Guard/Reserve.

The 5,291 soldiers had 13,087 records of encounters for heat illnesses that resulted in an average of 2.5 medical encounters per soldier (Table 2). The majority of the soldiers’ records indicated heat exhaustion diagnoses (69.3%), of which 98.0% were recorded during outpatient encounters. Similarly, 91.4% of heat stroke diagnoses were made during outpatient encounters. The number of heat stroke admissions was nearly double that of heat exhaustion; the number of hospital bed days associated with heat stroke admissions (786 bed days) was 3 times the number associated with heat exhaustion admissions (263 bed days) (data not shown).

The total Direct CareDirect care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.”direct care cost to the Army for heat stroke and heat exhaustion encounters was $7.3 million, or $559 per encounter. Even though approximately 70% of the medical encounters were related to heat exhaustion, cost was almost evenly divided between heat exhaustion and heat stroke encounters ($3.7 million and $3.6 million, respectively). The total cost of outpatient encounters was approximately 20% higher than the cost of inpatient admissions ($3.9 million and $3.3 million, respectively). An inpatient heat stroke encounter ($7,453/encounter) was more than 10-fold as costly as the aggregate cost per encounter ($559/encounter).

EDITORIAL COMMENT

This is the first report in the literature summarizing the direct medical costs associated with heat illness diagnoses among U.S. Army soldiers. A major strength of this study is its inclusion of all active Army and active and inactive National Guard/Reserve soldiers diagnosed with heat illnesses in outpatient and inpatient settings at both military treatment and civilian facilities. For example, in 2015, DeGroot and colleagues7 found an overall treatment cost of $408,074 for heat injuries occurring among 128 of the 10,580 soldiers attending Army Ranger School, which is held at 1 military installation. The DeGroot and colleagues study, which included only Army Ranger trainees, found that the cost per encounter for heat exhaustion treated at the Ranger aid station ranged from $176 to $216 per encounter. The authors estimated that the cost per encounter ranged from $3,024 to $4,327 for heat exhaustion treated but not admitted to a hospital (outpatient), while the cost of an encounter for heat stroke, as indicated by a hospital admission (inpatient), ranged from $5,000 to $6,878 per encounter.7 Using more precise encounter and hospitalization data from 5,291 U.S. Army soldiers with a heat injury over a 3-year period, the current study found a total direct care cost of $7,321,719 for heat injuries. The cost per encounter was $410 for heat exhaustion and $897 per heat stroke encounter.

Direct medical costs are only a portion of the total cost associated with heat illness. Indirect costs of illness account for costs associated with absenteeism, lost productivity, and decreased performance.8–10 In the military, there are lost productivity costs to the Army in the form of 1) lost duty days (or absenteeism), where the soldier is paid but is not able to perform the relevant duties because of health-related reasons, such as hospitalization, and 2) limited duty days, in which a soldier performs the relevant duties but at diminished capacity following an illness or injury.4,6 This analysis notes a total of 1,049 bed days (or lost duty days) due to heat illness diagnoses. Based on average soldier pay for the study timeframe and assuming the loss of 8 hours per day, these lost duty days total $356,000 in lost cost to the Army.

While data for medical profiles associated with heat illness were not available, the indirect costs of the lost and limited duty time associated with medical profiles have been estimated at almost 80% of the total cost of other injuries.4,6 If we assume this cost ratio for heat illness, indirect costs could reach $36 million. A future analysis should incorporate lost and/or limited duty heat illness profile data in order to provide a better estimate of the total cost of these conditions to the Army.

There were 2 main limitations to the study. The surveillance period for this report covered the period 1 January 2016 through 31 December 2018, so it is possible that some initial costs occurring before January 2016 and some follow-up and sequelae visits occurring after December 2018 were not accounted for in the full care cost for each heat illness event. Additionally, the cost assigned by the MHS to heat injury as a primary diagnosis reflects the intensity and complexity of care for other illnesses or injuries (e.g., gastroenteritis, stress fracture) that may be present at the time of the encounter.11

Author affiliations: Armed Forces Health Surveillance Branch, Silver Spring, MD (Dr. Forrest, Dr. Maule, Ms. McCabe, Ms. Kebisek, Mr. Steelman, and Dr. Ambrose).

Disclaimer: The contents, views, or opinions expressed in this publication are those of the author(s) and do not necessarily reflect the official policy or position of the Defense Health Agency or the Department of Defense.

REFERENCES

1. Armed Forces Health Surveillance Branch. Surveillance Case Definition. Heat illness. https://health.mil/Reference-Center/Publications/2019/10/01/Heat-Injuries. Accessed 20 February 2020.

2. Armed Forces Health Surveillance Branch. Update: Heat injures, active component, U.S. Armed Forces, 2018. MSMR. 2019;26(4):15–20.

3. Barnes SR, Ambrose JF, Maule AL, et al. Incidence, timing, and seasonal patterns of heat illnesses during U.S. Army basic combat training, 2014–2018. MSMR. 2019;26(4):7–14.

4. Hauschild VD, Lee T, Barnes S, Forrest L, Hauret K, Jones BH. The etiology of injuries in US Army initial entry training. US Army Med Dep J. 2018;(2-18):22–29.

5. Bulzacchelli MT, Sulsky SI, Zhu L, Brandt S, Barenberg A. The cost of basic training injuries in the U.S. Army: injury-related medical care and risk factors. Final Technical Report. Fort Belvoir, VA: Defense Technical Information Center.

6. Hauschild VD, Forrest LJ, Hirleman C, Pinyan EC, Grier T, Jones BH. Pectoralis major injuries in the Army, CY 2016 active duty Army. APHC PHIP No. 12-03-0719. Public Health Information Paper. Fort Belvoir, VA: Defense Technical Information Center.

7. DeGroot DW, Kenefick RW, Sawka MN. Impact of arm immersion cooling during Ranger training on exertional heat illness and treatment costs. Mil Med. 2015;180(11):1178–1183.

8. Johns G. Presenteeism in the workplace: a review and research agenda. J Organ Behav. 2010;31(4):519–542.

9. Mitchell RJ, Bates P. Measuring health-related productivity loss. Popul Health Manag. 2011;14(2):93–98.

10. Rice DP, Hodgson TA, Kopstein AN. The economic costs of illness: a replication and update. Health Care Financ Rev. 1985;7(1):61–80.

11. Defense Health Agency. Uniform Business Office User Guide. May 2018. https://health.mil/Reference-Center/Reports/2018/09/27/DHA-UBO-User-Guide-May-2018. Accessed 14 April 2020.

TABLE 1. Demographic and military characteristics of soldiers with heat illness encounters, U.S. Army, 2016–2018

TABLE 2. Medical encounters and direct care costs associated with heat illness, U.S. Army, 2016–2018

You also may be interested in...

Long-Acting Reversible Contraceptive Use, Active Component Service Women, U.S. Armed Forces, 2016–2020

Article
7/1/2021
Lt. Col. Paula Neemann, 15th Healthcare Operations Squadron clinical medicine flight commander, demonstrates several birth options, such as an intrauterine device, at the 15th MDG's contraceptive clinic at Joint Base Pearl Harbor-Hickam, Hawaii, May 6, 2021. The contraceptive clinic opened June 7 to service beneficiaries and provide same-day procedures without a referral. (U.S. Air Force photo by 2nd Lt. Benjamin Aronson)

Long-Acting Reversible Contraceptive Use, Active Component Service Women, U.S. Armed Forces, 2016–2020

Recommended Content:

Medical Surveillance Monthly Report

Oral Cavity and Pharynx Cancers, Active Component, U.S. Armed Forces, 2007–2019

Article
7/1/2021
Moist snuff, chewing tobacco is placed between cheek and gum. All varieties of smokeless tobacco can cause harmful effects on the oral cavity.

Oral Cavity and Pharynx Cancers, Active Component, U.S. Armed Forces, 2007–2019

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Medical Encounters for Snakebite Envenomation, Active and Reserve Components, U.S. Armed Forces, 2016–2020

Article
6/1/2021
Masters of camouflage, the Sidewinder Rattlesnakes are out and about aboard Marine Corps Logistics Base Barstow, California, May 11. Watch where you put your hands and feet, and observe children and pets at all times, as this is the natural habitat for these venomous snakes and a bite can cause serious medical problems. Notice the sharp arrow-shaped head with pronounced jaws, and the raised eye sockets, as well as the telltale rattles. Keep in mind, however, that rattles can be broken or lost, so you may or may not hear a rattle before they strike to protect themselves.

Brief Report: Medical Encounters for Snakebite Envenomation, Active and Reserve Components, U.S. Armed Forces, 2016–2020

Recommended Content:

Medical Surveillance Monthly Report

The Cost of Lower Extremity Fractures Among Active Duty U.S. Army Soldiers, 2017

Article
6/1/2021
X-ray image of a fractured tibia.

Recommended Content:

Medical Surveillance Monthly Report

Early Identification of SARS-CoV-2 Emergence in the Department of Defense via Retrospective Analysis of 2019–2020 Upper Respiratory Illness Samples

Article
6/1/2021
Army Maj. Raymond Nagley, S-3 officer assigned to the 50th Regional Support Group (RSG), receives a nasal swab to screen for COVID-19 at Fort Hood, Texas, on Feb. 5, 2021, from Spc. Yoali Muniz, a lab tech assigned to the 7406th Troop Medical Clinic, based in Columbia, Missouri. The 50th RSG, a Florida Guard unit based in Homestead, Florida, is preparing for deployment to Poland. (U.S. Army Guard photo by Sgt. 1st Class Shane Klestinski)

Early Identification of SARS-CoV-2 Emergence in the Department of Defense via Retrospective Analysis of 2019–2020 Upper Respiratory Illness Samples

Recommended Content:

Medical Surveillance Monthly Report

Department of Defense Mid-Season Vaccine Effectiveness Estimates for the 2019– 2020 Influenza Season

Article
6/1/2021
201019-N-PC065-1062 NORFOLK (Oct. 19, 2020) Hospital Corpsman 2nd Class Sashee Robinson, assigned to amphibious transport dock ship USS Arlington (LPD 24), administers an influenza vaccine to Machinery Repairman 2nd Class Hannah Swearingen in medical aboard the Arlington. Influenza vaccines are an annual medical readiness requirement throughout the Department of Defense. (U.S. Navy photo by Mass Communication Specialist 2nd Class John Bellino/Released)

Department of Defense Mid-Season Vaccine Effectiveness Estimates for the 2019– 2020 Influenza Season

Recommended Content:

Medical Surveillance Monthly Report

Morbidity Burdens Attributable to Various Illnesses and Injuries, Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2020

Article
5/1/2021
Navy Lt. James E. Lamb, left, and Sgt. Ryan Eskandary exercise aboard USS Pearl Harbor, May 6. Lamb is a Minneapolis native and serves as a firepower control team leader. Eskandary hails from St. Paul, Minn., and serves as a forward observer. Both serve with the 11th Marine Expeditionary Unit’s command element. The unit embarked USS Makin Island, USS New Orleans and USS Pearl Harbor in San Diego, Nov. 14, beginning a seven-month deployment to the Western Pacific, Horn of Africa and Middle East regions. (U.S. Navy photo by Cpl. Tommy Huynh, Arabian Sea/Released)

Morbidity Burdens Attributable to Various Illnesses and Injuries, Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2020

Recommended Content:

Medical Surveillance Monthly Report

Surveillance snapshot: Illness and injury burdens, recruit trainees, U.S. Armed Forces, 2020

Article
5/1/2021
A U.S. Marine Corps drill instructor with Golf Company, 2nd Recruit Training Battalion, motivates a recruit during a Marine Corps Martial Arts Program (MCMAP) training session at Marine Corps Recruit Depot, San Diego, Aug. 2, 2021. The drill instructors ensured recruits conducted the techniques safely and effectively during the training session. (U.S. Marine Corps photo by Cpl. Zachary T. Beatty)

Recommended Content:

Medical Surveillance Monthly Report

Surveillance snapshot: Illness and injury burdens, reserve component, U.S. Armed Forces, 2020

Article
5/1/2021
U.S. Army Col. Kris Marshall, co-director of Exercise Agile Spirit 2021, salutes during a closing ceremony August 6, 2021 at Orpholo Training Area, Georgia. Agile Spirit 21 promotes regional stability and security, while increasing readiness, strengthening partner capabilities and fostering trust. Agile Spirit provides vital opportunities, not only for multiple U.S. services to work together, but also for integrated, total force training with U.S. Reserve and National Guard units and our partner nations’ militaries to ensure interoperability. (U.S. Army National Guard photo by Cpl. Rydell Tomas)

Surveillance snapshot: Illness and injury burdens, reserve component, U.S. Armed Forces, 2020

Recommended Content:

Medical Surveillance Monthly Report

Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Non-service Member Beneficiaries of the Military Health System, 2020

Article
5/1/2021
MAYPORT, Fla. (Sept. 18, 2020) – Cmdr. Mary Gracia, a pediatric nurse practitioner at Naval Branch Health Clinic Mayport, checks five-year-old Gabriella’s ears. Gracia, a native of McAllen, Texas, says, “It's been an honor and a privilege to impart my expertise to the children of our active duty members who are graciously serving our country. These children, our future leaders, prayers lifted and bountiful blessings for each one. And to the children I've helped during overseas deployments, prayers continued.” (U.S. Navy photo by Jacob Sippel, Naval Hospital Jacksonville/Released).

Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Non-service Member Beneficiaries of the Military Health System, 2020

Recommended Content:

Medical Surveillance Monthly Report

Medical Evacuations out of the U.S. Central Command, Active and Reserve Components, U.S. Armed Forces, 2020

Article
5/1/2021
U.S. Army Soldiers from the 115th Brigade Support Battalion, 1st Armored Brigade Combat Team, evacuate casualties onto waiting HH-60M MEDEVAC Blackhawk helicopters from Charlie Company, 6th Battalion, 101st Combat Aviation Brigade during Combined Resolve XV, Feb. 27, 2021, at Hohenfels Training Area. Combined Resolve XV is a Headquarters Department of the Army directed Multinational exercise designed to build 1st Armored Brigade Combat Team, 1st Cavalry Division’s readiness and enhance interoperability with allied forces and partner nations to fight and win against any adversary.(U.S. Army photo by Sgt. 1st Class Garrick W. Morgenweck)

Medical Evacuations out of the U.S. Central Command, Active and Reserve Components, U.S. Armed Forces, 2020

Recommended Content:

Medical Surveillance Monthly Report

Hospitalizations, Active Component, U.S. Armed Forces, 2020

Article
5/1/2021
Hospitalizations, Active Component, U.S. Armed Forces, 2020

Hospitalizations, Active Component, U.S. Armed Forces, 2020

Recommended Content:

Medical Surveillance Monthly Report

Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Active Component, U.S. Armed Forces, 2020

Article
5/1/2021
U.S. Air Force Capt. Sean Wilson, a native of Winston-Salem, N.C., and a physical therapist with the 59th Orthopedic and Rehabilitation Squadron, teaches a patient some home exercises that he can perform on his own at the Craig Joint-Theater Hospital, Jan. 23, 2012. (U.S. Air Force photo by Spc.Cody Barber, Bagram Air Field, Afghanistan/Released)

Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Active Component, U.S. Armed Forces, 2020

Recommended Content:

Medical Surveillance Monthly Report

Ambulatory Visits, Active Component, U.S. Armed Forces, 2020

Article
5/1/2021
Tech. Sgt. Kimberly Weaver, 606th Air Control Squadron noncommissioned officer in charge of medical readiness, measures an Airman’s blood pressure at Aviano Air Base, Italy, May 10, 2021. The primary job of an Independent Duty Medical Technician is to ensure the health and safety of Airmen and their families. (U.S. Air Force photo by Senior Airman Ericka A. Woolever)

Recommended Content:

Medical Surveillance Monthly Report

Update: Exertional Hyponatremia, Active Component, U.S. Armed Forces, 2005–2020

Article
4/1/2021
Tech. Sgt. Kimberly Weaver, 606th Air Control Squadron noncommissioned officer in charge of medical readiness, measures an Airman’s blood pressure at Aviano Air Base, Italy, May 10, 2021. The primary job of an Independent Duty Medical Technician is to ensure the health and safety of Airmen and their families. (U.S. Air Force photo by Senior Airman Ericka A. Woolever)

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 14

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.