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Trends in Prevalence of CKD Stages 3–5 in the Military Health System

The crude prevalence of Military Health System (MHS) beneficiaries with CKD stages 3–5 (eGFR <60 ml/min/1.73²) ranged from 4.9 to 6.4% during 2009–2019. From 2017 on, the crude prevalence was stable around 5.4%, while the age-standardized prevalence was 6.3–6.4%. The crude prevalence of CKD stages 3–5 was highest in adults aged ≥70 years and Black adults. The age-standardized prevalence was highest in Black adults compared with their counterparts.

Data Source: DoD-MHS

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Prevalence of CKD Stages 3-5 in the Military Health System by Overall (%) Department of Defense Military Health System
2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019
6.4	6.0	5.3	5.3	5.1	5.0	4.9	5.1	5.4	5.4	5.4

Prevalence of CKD Stages 3-5 in the Military Health System by Overall (%) Department of Defense Military Health System
2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019
8.0	7.6	7.0	7.0	6.6	6.4	6.1	6.1	6.4	6.3	6.4

The estimated glomerular filtration rate (eGFR in ml/min/1.73m²) was calculated from serum creatinine using the 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation which does not include race as a variable. Adults on dialysis or who received kidney transplants (identified by ICD-9 or ICD-10 codes) were excluded from eGFR calculations. Estimates were standardized to the 2010 U.S. Census population.

The US Department of Defense Military Health System (MHS) provides comprehensive primary and specialty care for more than 9.6 million active-duty personnel and military retirees and their families worldwide. The MHS Data Repository (MDR) is the administrative claims database for all care received through MHS, including direct care received in military treatment facilities and purchased care received in civilian treatment facilities. The MDR does not capture health care delivery in combat zones or care received in the VHA system. All patients were in the TRICARE Prime managed care option. Data are from both the direct care (military facilities) and private care (private facilities through TRICARE coverage) systems.

De-identified patient data were obtained from the MHS data repository. Data contain both the estimated glomerular filtration rate (eGFR) definition of chronic kidney disease (CKD) and claims-based CKD defined by using ICD-9-CM and ICD-10-CM codes diagnosis codes with at least one inpatient or two outpatient CKD diagnoses. To be included in analyses, service members and their dependents had to have at least one inpatient or outpatient record during the fiscal year (October 1 to September 30). Data cells with 10 or fewer patients were suppressed.

Disclaimer: The views expressed are those of the authors and do not reflect the official policy of the Uniformed Services University, Departments of Army/Navy/Air Force, Department of Defense, Centers for Disease Control and Prevention, Department of Health and Human Services, or US government.

Field	Data
Description of Measure	Prevalence of Department of Defense Military Health System beneficiaries with eGFR <60 mL/min/1.73 m².
Data Set	U.S. Department of Defense Military Health System (MHS) Data Repository (MDR). MDR source files: CAPER (direct care outpatient claims), SIDR (direct care inpatient claims), TED-NI (private care outpatient claims), TED-I Header (private care inpatient claims), CHEMISTRY (laboratory data), and VM6BEN (demographic information from the Defense Enrollment Eligibility Reporting System).
Population	Beneficiaries aged ≥ 18 years enrolled in the TRICARE Prime or Plus managed care options.
Years Included	Fiscal years 2009−2019 (October 1, 2008 to September 30, 2019).
Numerator	Population in denominator that met the definition of CKD described below. Data cells with less than 11 counts were suppressed.
Denominator	Population with an outpatient serum creatinine value available during the fiscal year. Adults with a diagnosis of dialysis or transplant were excluded. Data cells with less than 11 counts were suppressed.
Definition of CKD	CKD was defined by an average estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² over the fiscal year. Serum creatinine measured during inpatient encounters were excluded. Outlier values (serum creatinine ≤ 0 mg/dL or > 25 mg/dL, or eGFR > 200 ml/min/1.73 m²) were excluded. Beneficiaries with diagnosis of dialysis or transplant were excluded from eGFR categorization.
Estimated Glomerular Filtration Rate (eGFR)	Based on the CKD-EPI (2021) equation for calibrated creatinine: eGFR=142 x [min(serum creatinine in mg/dL) /κ, 1)]α x [max(serum creatinine/κ, 1)]-1.20 x 0.9938age x (1.012 if female). κ = 0.7 if female and 0.9 if male α = -0.241 if female and -0.302 if male = raise to the power
Serum Creatinine	Laboratory measurements taken during outpatient encounters.
ICD-9 and ICD-10 Codes	Dialysis (ICD-9): V45.1, V45.0, V56.1, V56.2, V56.3, V56.31, V56.32, V56.8, E879.1. Dialysis (ICD-10): I95.3, R88.0, T81.502A, T81.502D, T81.502S, T81.512A, T81.512D, T81.512S, T81.522A, T81.522D, T81.522S, T81.532A, T81.532D, T81.532S, T81.592A, T81.592D, T81.592S, T82.41XA, T82.41XD, T82.41XS, T82.42XA, T82.42XD, T82.42XS, T82.43XA, T82.43XD, T82.43XS, T82.49XA, T82.49XD, T82.49XS, T85.611A, T85.611D, T85.611S, T85.621A, T85.621D, T85.621S, T85.631A, T85.631D, T85.631S, T85.691A, T85.691D, T85.691S, T85.71XA, T85.71XD, T85.71XS, Y62.2, Y84.1, Z49.01, Z49.02, Z49.31, Z49.32, Z91.151, Z91.158, Z91.A5, Z99.2. Transplant (ICD-9): V42.0, 996.81. Transplant (ICD-10): T86.10, T86.11, T86.12, T86.13, Z48.22, Z94.0.
Dialysis and Transplant	Beneficiaries with ≥ 1 inpatient or ≥ 2 outpatient encounters with ICD-9 or ICD-10 codes for dialysis or transplant were excluded.
Age Standardization	Estimates were standardized to the 2010 U.S. Census population for adults: 18–39 years: 37.1%, 40–59 years: 38.1%, 60–69 years: 12.8%, and 70+ years: 12.0%.
Limitations of Indicator	The occurrence of CKD stages 1 and 2 cannot be calculated as results from urine albumin or urine protein testing are not included. In the MHS, each year approximately 60% of all adults do not have an outpatient serum creatinine measured, and another 10% have serum creatinine measured only in the private sector with unavailable results.
Analytical Considerations	In published literature, CKD is defined by serum creatinine in alternate ways (single measurement, average of multiple measurements, persistence > 90 days). Care must be taken in making comparisons. Active-duty service members constitute around 43% of MHS beneficiaries and tend to be younger and healthier than the general population. Therefore, testing for serum creatinine is performed less frequently than in other health care systems.