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Service Members and Their Dependents with eGFR-based CKD Stages 3–5 Who Also Have a Diagnosis Code for CKD in the Military Health System

For MHS beneficiaries with CKD stages 3–5 based on eGFR, the crude prevalence of those who also had an ICD-9 diagnosis code for CKD was 25.0%–36.5% in 2009–2015. After conversion to ICD-10 in 2016, the prevalence was around 30.0%–36.0% in 2016–2023. The crude percentage of adults with a diagnosis code was higher in adults aged ≥50 years, those with CKD stages 4−5, and men compared with the corresponding counterparts. During 2009–2023, no distinct patterns were observed within specific race and ethnicity groups.

Data Source: DoD-MHS

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Percentage of Service Members with CKD Stages 3-5 Who Have a Diagnosis Code for CKD in the Military Health System by Overall (%) Department of Defense Military Health System
2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021	2022	2023
25.0	31.6	34.1	34.4	35.2	35.6	36.5	31.7	32.0	32.2	32.0	30.1	36.0	35.3	35.2

The eGFR in ml/min/1.73² was calculated from serum creatinine using the 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.¹ End-stage kidney disease (ESKD) in adults (dialysis and transplant) who were 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	Percentages of Department of Defense Military Health System beneficiaries with eGFR < 60 mL/min/1.73 m² and ICD-9 or ICD-10 codes indicating a CKD diagnosis.
Data Set	Source files from U.S. Department of Defense MHS Data Repository (MDR). ICD Coding: GENESIS Encounter (BDE 3.0, direct care), GENESIS Admission Table (BDE 3.0, direct care), CAPER (direct care outpatient claims), SIDR (direct care inpatient claims), TED-NI (private care outpatient claims), TED-I Header (private care inpatient claims), Laboratories: CDR Chemistry, SIDR, CADRE Laboratory Enhanced, GENESIS Laboratory Results (BDE 3.0), TED-NI (private-sector laboratory claims) Demographics: VM6BEN (demographic information from the Defense Enrollment Eligibility Reporting System), GENESIS Person (BDE 3.0). BDE: Bulk Data extract, CADRE: Comprehensive Ancillary Data Record Extract, CAPER: Comprehensive Ambulatory/Professional Encounter Record, CDR: Clinical Data Repository, GENESIS: name of the MHS EHR, SIDR: Standard Inpatient Data Record, TED-I: TRICARE Encounter Data – Institutional, TED-NI: TRICARE Encounter Data – Non-Institutional
Population	Beneficiaries of age ≥ 18 years enrolled in the TRICARE Prime or Plus managed care options.
Years Included	Fiscal years 2009–2023 (October 1, 2008, to September 30, 2023).
Numerator	People had ≥1 inpatient or ≥2 outpatient encounters with matching ICD-9 or ICD-10 codes for CKD during the fiscal year among the denominator population. Data cells with less than 11 counts were suppressed.
Denominator	Population with CKD by eGFR as described in the definition of CKD. Data cells with less than 11 counts were suppressed.
Definition of CKD	CKD was defined by an average 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 a diagnosis of dialysis or transplant were excluded from eGFR categorization and the denominator. Of all MHS beneficiaries with serum creatinine measured during 2009–2023, only 0.12%–0.20% were on dialysis and only 0.14%–0.19% had received a transplant.
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
ICD-9 and ICD-10 Codes	CKD (ICD-9): 16, 95.4, 189, 189.1, 189.9, 236.91, 250.4, 250.41, 250.42, 250.43, 271.4, 274.1, 283.11, 403, 403.01, 403.1, 403.11, 403.9, 403.91, 404, 404.01, 404.02, 404.03, 404.1, 404.11, 404.12, 404.13, 404.9, 404.91, 404.92, 404.93, 405.01, 440.1, 442.1, 447.3, 453.3, 572.4, 580, 580.4, 580.81, 580.89, 580.9, 581, 581.1, 581.2, 581.3, 581.81, 581.89, 581.9, 582, 582.1, 582.2, 582.4, 582.81, 582.89, 582.9, 583, 583.1, 583.2, 583.4, 583.6, 583.7, 583.81, 583.89, 583.9, 584.5, 584.6, 584.7, 584.8, 584.9, 585.x, 586, 587, 588, 588.1, 588.81, 588.89, 588.9, 589, 590, 590.8, 591, 593.1, 593.3, 593.4, 593.5, 593.6, 593.7, 593.81, 593.89, 593.9, 642.1, 646.2, 753, 753.1, 753.11, 753.12, 753.13, 753.14, 753.15, 753.16, 753.17, 753.19, 753.2, 753.21, 753.22, 753.23, 753.29, 753.3, 753.4, 753.5, 753.6, 753.7, 753.8, 753.9, 791, 791.1, 791.2, 791.3, 791.4, 791.5, 791.6, 791.7, 791.9, 794.4, 585.6, 996.81, V42.0, V45.1, V56.0, V56.1, V56.2, V56.3, V56.31, V56.32, V56.8, E879.1. CKD (ICD-10): A18.11, B58.83, C64.1, C64.2, C64.9, C65.1, C65.2, C65.9, C66.1, C66.2, C66.9, C79.00, C79.01, C79.02, C7A.093, D30.00, D30.01, D30.02, D30.10, D30.11, D30.12, D30.20, D30.21, D30.22, D3A.093, D41.00, D41.01, D41.02, D41.10, D41.11, D41.12, D41.20, D41.21, D41.22, D49.511, D49.512, D49.519, D51.1, D86.84, E08.21, E08.22, E08.29, E09.21, E09.22, E09.29, E10.21, E10.22, E10.29, E11.21, E11.22, E11.29, E13.21, E13.22, E13.29, E26.81, E72.00, E72.01, E72.02, E72.03, E72.04, E72.09, E72.53, E83.31, E87.21, E87.22, I12.0, I12.9, I13.0, I13.10, I13.11, I13.2, I15.0, I15.1, I72.2, I75.81, I77.73, I77.82, I82.3, M32.14, M32.15, M35.04, M35.0A, N02.0, N02.1, N02.2, N02.3, N02.4, N02.5, N02.6, N02.7, N02.8, N02.9, N02.A, N03.0, N03.1, N03.2, N03.3, N03.4, N03.5, N03.6, N03.7, N03.8, N03.9, N03.A, N04.0, N04.1, N04.2, N04.3, N04.4, N04.5, N04.6, N04.7, N04.8, N04.9, N04.A, N05.0, N05.1, N05.2, N05.3, N05.4, N05.5, N05.6, N05.7, N05.8, N05.9, N05.A, N06.0, N06.1, N06.2, N06.3, N06.4, N06.5, N06.6, N06.7, N06.8, N06.9, N06.A, N07.0, N07.1, N07.2, N07.3, N07.4, N07.5, N07.6, N07.7, N07.8, N07.9, N07.A, N08, N11.0, N11.1, N11.8, N11.9, N12., N13.0, N13.1, N13.2, N13.30, N13.39, N13.4, N13.5, N13.6, N13.70, N13.71, N13.721, N13.722, N13.729, N13.731, N13.732, N13.739, N13.8, N13.9, N14.0, N14.11, N14.19, N14.2, N14.3, N14.4, N15.0, N15.1, N15.8, N15.9, N16, N18.1, N18.2, N18.30, N18.31, N18.32, N18.4, N18.5, N18.6, N18.9, N21.0, N21.1, N21.8, N21.9, N22, N23, N25.1, N25.89, N25.9, N26.1, N26.2, N26.9, N27.0, N27.1, N27.9, N28.0, N28.1, N28.81, N28.82, N28.83, N28.84, N28.85, N28.86, N28.89, N28.9, N29, O10.211, O10.212, O10.213, O10.219, O10.22, O10.23, O10.311, O10.312, O10.313, O10.319, O10.32, O10.33, O26.831, O26.832, O26.833, O26.839, P96.0, Q27.1, Q27.2, Q60.0, Q60.1, Q60.2, Q60.3, Q60.4, Q60.5, Q60.6, Q61.00, Q61.01, Q61.02, Q61.11, Q61.19, Q61.2, Q61.3, Q61.4, Q61.5, Q61.8, Q61.9, Q62.0, Q62.10, Q62.11, Q62.12, Q62.2, Q62.31, Q62.32, Q62.39, Q62.4, Q62.5, Q62.60, Q62.61, Q62.62, Q62.63, Q62.69, Q62.7, Q62.8, Q63.0, Q63.1, Q63.2, Q63.3, Q63.8, Q63.9, Q79.4, Q79.51, R80.1, R80.3, R80.8, R80.9, R82.991, R82.992, R82.993, R82.994, R88.0, T86.10, T86.11, T86.12, T86.13, T86.19, Z48.22, Z49.31, Z49.32, Z52.4, Z85.520, Z85.528, Z85.53, Z85.54, Z87.441, Z90.5, Z94.0. 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.
Serum Creatinine	Laboratory measurements taken during outpatient encounters.
Dialysis and Transplant	Beneficiaries with ≥ 1 inpatient or ≥ 2 outpatient encounters with ICD-9 or ICD-10 codes for dialysis or transplant were excluded and an eGFR was not calculated.
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 urine albumin testing was not included. In the MHS, each year approximately 50% 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. Reporting of race and ethnicity data has improved over time. In 2009, combined Unknown or Missing race and ethnicity was 52.1% of the CKD stage 3–5 population. By 2023, Unknown or Missing race and ethnicity was 10.4% of the CKD stage 3–5 population.
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. Our analysis used the average of measurements during the fiscal year in order to present data on a year-by-year basis.
Disclaimer	The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions, or policies of the Uniformed Services University of the Health Sciences (USUHS), the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the Departments of the Army, Navy, or Air Force, or the Department of Health and Human Services.

Inker LA, Eneanya ND, Coresh J, et al. New creatinine- and cystatin C–based equations to estimate GFR without race. N Engl J Med. 2021;385:1737-1749. doi: 10.1056/NEJMoa2102953