National Academies Press: OpenBook
Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
×

IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS FOR VETERANS

Committee on Evaluation of the Presumptive Disability Decision-Making Process for Veterans

Board on Military and Veterans Health

Jonathan M. Samet and Catherine C. Bodurow, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
×

THE NATIONAL ACADEMIES PRESS

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract No. V101 (93) P-2136 between the National Academy of Sciences and United States Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

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Suggested citation: IOM (Institute of Medicine). 2008. Improving the presumptive disability decision-making process for veterans. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
×

“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES


Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine


The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.


The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.


The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.


The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.


www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
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COMMITTEE ON EVALUATION OF THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS FOR VETERANS

JONATHAN M. SAMET (Chair), Professor and Chair,

Department of Epidemiology,

Jacob I. and Irene B. Fabrikant Professor in Health, Risk, and Society,

Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD

MARGARET A. BERGER, Suzanne J. and Norman Miles Professor of Law,

Brooklyn Law School, NY

KIRSTEN BIBBINS-DOMINGO, Assistant Professor of Medicine and of Epidemiology, Biostatistics,

University of California, San Francisco

ERIC G. BING, Endowed Professor of Global Health and HIV,

Charles R. Drew University of Medicine and Science, Los Angeles, CA

BERNARD D. GOLDSTEIN, Professor of Environmental and Occupational Health,

Graduate School of Public Health, University of Pittsburgh, PA

GUY H. McMICHAEL III, President,

GHM Consulting, Washington, DC

JOHN R. MULHAUSEN, Director,

Corporate Safety and Industrial Hygiene, 3M Company, St. Paul, MN

RICHARD P. SCHEINES, Professor and Head,

Department of Philosophy, Carnegie Mellon University, Pittsburgh, PA

KENNETH R. STILL, President and Scientific Director,

Occupational Toxicology Associates, Inc., Hillsboro, OR

DUNCAN C. THOMAS, Verna Richter Chair in Cancer Research, Professor, and Director,

Biostatistics Division, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles

SVERRE VEDAL, Professor,

Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health and Community Medicine, Seattle

ALLEN J. WILCOX, Senior Investigator,

Epidemiology Branch, National Institute of Environmental Health Sciences, and

Editor-in-Chief of Epidemiology,

Durham, NC

SCOTT L. ZEGER, Frank Hurley-Catharine Dorrier Professor and Chair,

Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD

LAUREN ZEISE, Chief,

Reproductive and Cancer Hazard Assessment Branch, Office of Environmental Health Hazard Assessment, California Environmental Protection Agency, Oakland

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
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Volunteer Scientific Consultant

MELISSA McDIARMID, Professor of Medicine,

Occupational Health Program, University of Maryland School of Medicine, Baltimore

Consultant

ROBERT J. EPLEY, Independent Consultant,

Waxhaw, NC

Staff

CATHERINE BODUROW, Study Director

MORGAN A. FORD, Program Officer (May-August 2007)

LESLIE SIM, Program Officer (February-May 2006)

ALICE VOROSMARTI, Research Associate (May-August 2007)

CARA JAMES, Research Associate (June 2006-May 2007)

ANISHA DHARSHI, Research Associate (June 2006-January 2007)

KRISTEN BUTLER, Research Assistant (March-July 2007)

KRISTEN GILBERTSON, Research Assistant (February-July 2006)

JON Q. SANDERS, Program Associate (March 2006-May 2007)

REINE Y. HOMAWOO, Senior Program Assistant (May-August 2007)

VERA DIAZ, Intern (February-April 2007)

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
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BOARD ON MILITARY AND VETERANS HEALTH

ROBERT B. WALLACE (Chair), Professor of Epidemiology and Internal Medicine, and Director,

Center on Aging, College of Public Health, University of Iowa, Iowa City

GEORGE K. ANDERSON, Executive Director,

Association of Military Surgeons in the United States, Bethesda, MD

MICHAEL S. ASCHER, Senior Medical Advisor,

Defense Biology Biosciences Directorate, Lawrence Livermore National Laboratory, Livermore, CA

ARTHUR J. BARSKY, Professor of Psychiatry,

Harvard Medical School, and

Director of Psychiatric Research,

Brigham and Women’s Hospital, Boston, MA

DIANA D. CARDENAS, Professor and Chair,

Department of Rehabilitation Medicine, University of Miami, FL

LINDA D. COWAN, Professor,

University of Oklahoma College of Public Health, Oklahoma City

TIMOTHY R. GERRITY, Senior Partner,

Noventus Medical, Worcester, MA

KATHERINE L. HEILPERN, Acting Chair,

Department of Emergency Medicine, Emory School of Medicine, Atlanta, GA

MYRON M. LEVINE, Head,

Division of Geographic Medicine, and

Director,

Center for Vaccine Development, University of Maryland School of Medicine, Baltimore

SUSAN H. MATHER,

Department of Veterans Affairs (Retired), Bowie, MD

MATTHEW L. PUGLISI, Director,

Business Development, Aptima, Inc., Washington, DC

PHYLLIS W. SHARPS, Professor and Director,

Master’s Program, Johns Hopkins University School of Nursing, Baltimore, MD

ERNEST T. TAKAFUJI, Director,

Office of Biodefense Research, National Institute of Allergy and Infectious Diseases, Bethesda, MD

Board Staff

FREDERICK ERDTMANN, Director

PAMELA RAMEY-McCRAY, Administrative Assistant

ANDREA COHEN, Financial Associate

IOM boards do not review or approve individual reports and are not asked to endorse conclusions and recommendations. The responsibility for the content of the reports rests with the authoring committee and the institution.

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Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

Dan G. Blazer, Duke University Medical Center

Mark R. Cullen, Yale University School of Medicine

Lynn R. Goldman, Johns Hopkins Bloomberg School of Public Health

Steven N. Goodman, Johns Hopkins University School of Medicine

Robert F. Herrick, Harvard School of Public Health

Susan H. Mather, Department of Veterans Affairs (Retired)

Francis L. O’Donnell, Department of Defense’s Force Health Protection and Readiness Programs

Louise M. Ryan, Harvard School of Public Health

Patrick Ryan, PricewaterhouseCoopers

David A. Savitz, Mount Sinai School of Medicine

Harold C. Sox, American College of Physicians and Internal Medicine

Michael A. Stoto, Georgetown University

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
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Judith P. Swazey, The Acadia Institute

Joseph Thompson, Aequus, Inc.

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Gilbert S. Omenn, University of Michigan Medical School, and Willard G. Manning, University of Chicago. Appointed by the National Research Council and Institute of Medicine, respectively, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
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Preface

This committee, the Committee on Evaluation of the Presumptive Disability Decision-Making Process for Veterans (Committee), was charged with describing the current process for how presumptive decisions are made for veterans who have health conditions arising from military service and with proposing a scientific framework for making such presumptive decisions in the future. Although an individual veteran can establish a direct service connection for an illness, the needed information on the responsible exposure received during military service may be unavailable or incomplete. Additionally, there may be scientific uncertainty as to whether the exposure is known to cause the health condition. To ensure that veterans are compensated when information for direct service connection is needed but unavailable, Congress or the Secretary of the Department of Veterans Affairs (VA) can decide to service connect entire groups of veterans for specific health conditions due to exposures received during service. This decision to compensate particular groups of veterans is called a presumptive disability service-connection decision or, simply, a presumption. A presumption may address unavailable or incomplete information on exposure or gaps in the evidence as to whether the exposure increases risk for the health condition.

Each veteran identified as eligible for coverage under a presumptive decision will have a separate, individual disability rating conducted by the VA and will be eligible for disability compensation based on the nature and severity of the health condition. That is, the presumptive disability service-connection decision is separate from the rating evaluation and compensation process.

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
×

The Committee took on the task of addressing presumptions while the United States was involved in conflict in Iraq and Afghanistan and veterans from prior conflicts were developing health conditions linked to service in Vietnam and the 1990 Persian Gulf War. The Committee’s charge involved examination of the processes used by all participants in the presumptive disability decision-making process for veterans—Congress, VA, the National Academies (National Research Council [NRC] and Institute of Medicine [IOM]), veterans service organizations, and veterans. The Committee examined the processes used by the NRC and IOM to evaluate scientific evidence in support of presumptive disability decision-making by the VA and how the VA used the syntheses and scientific classifications of the NRC and IOM, along with other information, to establish presumptive decisions. The Committee was asked to describe the current process. The Committee’s approach involved a series of case studies, intended to draw out “lessons learned” that would inform the development of a new approach. The case studies are not intended as criticisms about the work of past NRC or IOM committees or previously established presumptive decisions by Congress and VA. Rather the case studies serve as an appropriate and informative foundation for proposing an approach for the future.

The Committee concluded that the presumptive disability decision-making process should be based on evidence about veterans’ health and how their health had been affected by military service. The Committee proposes a framework for the future that will be based on findings about the health of veterans that come from careful charting of Service member exposures during military service and tracking of their health at entry into, during, at separation from and after military service. The proposed framework may be applied to all types of exposures (e.g., chemical, biological, infectious, physical, and psychological); however, we recognize that characterizing psychological stressors, particularly under combat circumstances, is particularly difficult, although highly relevant to the chronic neuropsychiatric disorders faced by veterans. The Committee offers its framework for evaluation of the resulting evidence and for considering the evidence from studies of veterans in the context of all other relevant lines of scientific evidence. The Committee recommends a two-step approach for evaluation of scientific evidence on exposures of military personnel and risks to health. The first step is to determine the strength of evidence in support of causation and to classify the strength of the causal classification. The second step is to describe the magnitude of the disease burden caused by the exposure in a specific group of veterans.

Presumptive decisions, while based in evidence on risks to health status, are also affected by other considerations. The report acknowledges these considerations. The Committee recognizes that its proposed framework for the future will be applied in a context set by many considerations beyond

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the scope of scientific evidence and its classification with regard to the strength of evidence for causality. Nonetheless, the Committee respectfully hopes that the Veterans’ Disability Benefits Commission will recommend and that Congress and the VA will adhere to an evidence-based approach for the future presumptive disability decision-making process for veterans.

I am highly appreciative of the dedication and work of the members of the Committee on Evaluation of the Presumptive Disability Decision-Making Process for Veterans. They willingly took on this important effort at a time when every American is aware of the great sacrifices that military service men and women and our veterans have and do make each day. The Committee addressed its charge with great dedication and worked tirelessly to consider all of the relevant information, to deliberate at length in committee meetings and conference calls. Of course, each committee member invested substantial time in this effort, reflective of its importance and of its challenging nature. The proposed scientific framework, levels for strength of evidence, and other recommendations in this report reflect the thoughtful and carefully considered conclusions of the Committee. The Committee wishes to express its appreciation for the valuable support of its dedicated staff directed by Catherine Bodurow. This report would not have been possible without their contributions.

Veterans have sacrificed a great deal for our nation. We owe them the best possible process for ensuring that those having service-related health conditions are properly identified, treated, and compensated.


Jonathan M. Samet, M.D., M.S.

Chair, Committee on Evaluation of the Presumptive Disability Decision-Making Process for Veterans

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
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Acknowledgments

The Committee on Evaluation of the Presumptive Disability Decision-Making Process for Veterans (Committee) and Institute of Medicine (IOM) staff would like to thank many individuals for providing information, data, discussions, and comments throughout this study. The Committee and IOM staff are indebted to these individuals for their assistance and contributions.

The Committee and IOM staff would like to acknowledge and thank members of the Veterans’ Disability Benefits Commission (VDBC) for taking time to attend and participate at the Committee’s open session meetings. The commissioners include: James T. Scott (VDBC’s Chairman), John Grady, Rick Surratt, and Joe Wynn. We would also like to recognize the VDBC Staff for their attendance and participation at the Committee’s open session meetings as well as any needed technical assistance throughout the study. These individuals include: Ray Wilburn (VDBC’s Executive Director), Jacqueline Garrick, Kathleen Greve, Steve Riddle, Jim Wear, and Donald Zeglin. IOM staff is appreciative of the assistance provided by Marcelle Habibion (Department of Veterans Affairs’ [VA] Director of Program Evaluation Service in the Office of Policy and Planning) during the course of the study. Many others from VA also provided information, presented at Committee meetings or participated in meetings with the Committee Chair and IOM staff. They are recognized, as follows, in alphabetical order: David Barrans, Mark Brown, Douglas Dembling, Lawrence Deyton, Patrick Dunne (VA’s Assistant Secretary for Policy and Planning), George Fitzelle, Duane Fleming, Bradley Flohr, Paul Hutter (VA’s Acting General

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
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Counsel), P. Craig Hyams, Patrick Joyce, Gordon Mansfield (VA’s Deputy Secretary), David McLenachen, Thomas Pamperin, and Joseph Salvatore.

The Committee benefited greatly from the knowledge, information, and views of presenters and panelists at its three open session meetings. The Committee would like to recognize the following individuals from its open session meeting on May 31, 2006 (listed in order of their presentation): John Grady (VDBC), Rick Surratt (VDBC), Joe Wynn (VDBC), Ray Wilburn (VDBC), Thomas Pamperin (VA), David Barrans (VA), Mark Brown (VA), Patrick Joyce (VA), and Bradley Flohr (VA). The Committee would like to recognize the following individuals who presented at its second open session meeting on July 27, 2006 (listed in order of their presentation): Rose Marie Martinez (IOM), Han Kang (VA), Lawrence Deyton (VA), R. Craig Postlewaite (DoD), Jack M. Heller (DoD), John Seibert (DoD), Cathy Wiblemo (The American Legion), Leonard Selfon (United Spinal Association), Quentin Kinderman (Veterans of Foreign Wars of the United States), and Rick Weidman (Vietnam Veterans of America). Finally, the Committee would like to recognize the following individuals who presented at its third open session meeting on October 4, 2006 (listed in order of their presentation): Laura Petrou, Patrick Ryan, Edward Scott, Chris Yoder, Nhan Do (DoD), Cliff Freeman (VA), and James T. Scott (VDBC’s Chairman). In addition, several congressional staffers joined a panel discussion in person or by phone. They are recognized in alphabetical order, as follows: William Brew, Kelly Craven, Mary Ellen McCarthy, Paige McManus, Dahlia Melendrez, Kingston Smith, Jon Towers, and Lupe Wissel.

Representatives of the Department of Defense (DoD) contributed to the Committee’s efforts by attending and presenting at open session meetings, participating in conference calls, and providing written responses to Committee questions. The Committee and IOM staff would like to thank Ellen Embrey (DoD’s Deputy Assistant Secretary of Defense for Force Health Protection and Readiness), along with Michael Kilpatrick and George Johnson of her office, for making the assistance and expertise of many in DoD available to the Committee and IOM staff. IOM staff would like to acknowledge Craig Postlewaite who facilitated and participated in each of the DoD, Committee, and IOM staff interactions. The following individuals (listed in alphabetical order) contributed substantial time and effort to providing the Committee documents, answers to questions and participating at panel discussions during open session meetings: Kenneth Cox, Donna Doganiero, Jack Heller, Brad Hutchens, Jack Jeter, Bill Monk, Christine Moser, John Seibert, Becky Sobel, and Hew Wolf.

Throughout the course of the study, the Committee received written comments from veterans service organizations, individual veterans, and the public. These comments served to heighten awareness of important issues

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that the Committee considered during its deliberations of the proposed levels for strength of evidence, proposed framework for the presumptive disability decision-making process, and recommendations. The Committee and IOM staff are grateful for the level of interest demonstrated and information that was shared.

IOM staff assembled an extensive electronic library of public laws, Federal Register notices, and all related presumptive disability decision documents with the assistance of librarians and experts at the Library of Congress. These individuals provided assistance in assembling an enormous knowledge base—from microfiche to electronic files—for the Committee, which was extensively researched and used throughout the study process. IOM staff is greatly indebted to the staff at the Library of Congress for these efforts.

The Committee was provided invaluable background information and expertise from IOM staff, including Rose Marie Martinez, David Butler, Jennifer Cohen, Carolyn Fulco, Abigail Mitchell, and Mary Paxton, during the course of the study. The Committee would like to thank these individuals for their contributions.

The Committee was fortunate to have the assistance of two knowledgeable consultants throughout the study. Melissa McDiarmid provided invaluable scientific input to the Committee’s efforts. Robert Epley provided guidance on VA processes and background. The Committee is indebted to both of these individuals for the time and efforts they contributed.

Finally, the Committee would like to acknowledge the support of the IOM staff. The Committee would like to recognize, in particular, the efforts of Catherine Bodurow (Study Director) who worked tirelessly over the course of the study. The Committee is also particularly appreciative of the efforts of Morgan Ford (Program Officer), Alice Vorosmarti (Research Associate), and Reine Homawoo (Senior Program Assistant) who supported the study at its conclusion and delivered this report. The Committee would also like to recognize Frederick Erdtmann (Board Director) who attended each of the Committee meetings and provided assistance throughout the study. There were many who provided part-time staff support to the committee’s efforts over the course of the study. These additional staff included: Leslie Sim (Program Officer), Cara James (Research Associate), Anisha Dharshi (Research Associate), Kristen Butler (Research Assistant), Kristen Gilbertson (Research Assistant), Jon Sanders (Program Associate), and Vera Diaz (Intern). Additional staff support included assistance from: Andrea Cohen (Financial Associate), Pamela Ramey-McCray (Administrative Assistant), Lara Andersen (Office of Reports and Communication), and Mark Goodin (Copyeditor). The staff would also like to acknowledge William McLeod (Senior Librarian, The National Academies) who provided invaluable support throughout the study.

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Appendixes1

 

 

A

 

Statement of the Veterans’ Disability Benefits Commission to the Institute of Medicine’s Committee on the Presumptive Disability Decision-Making Process, May 31, 2006

 

339

B

 

Committee on Evaluation of the Presumptive Disability Decision-Making Process for Veterans Open Session Meeting Agendas

 

344

C

 

Glossary

 

349

D

 

Historical Background

 

 

E

 

Arguments Favoring and Opposing Presumptions

 

 

F

 

Tables: Summary of Presumptive Disability Decision-Making Legislative History

 

 

G

 

VA’s White Paper on the Presumptive Disability Decision-Making Process

 

 

H

 

IOM’s Statements of Task and Conclusions for Agent Orange and Gulf War Reports

 

 

I

 

Case Studies

 

 

   

 1:  Mental Disorders’ Presumptions

 

 

   

 2:  Multiple Sclerosis Presumption

 

 

   

 3:  Prisoners of War Presumptions

 

 

   

 4:  Amputees and Cardiovascular Disease Presumption

 

 

   

 5:  Radiation Presumptions

 

 

   

 6:  Mustard Gas and Lewisite Presumptions

 

 

   

 7:  Gulf War Presumptions

 

 

   

 8:  Agent Orange and Prostate Cancer Presumption

 

 

   

 9:  Agent Orange and Type 2 Diabetes Presumption

 

 

   

 10:  Spina Bifida Program

 

 

J

 

Causation and Statistical Causal Methods

 

 

K

 

Sources of Health and Exposure Data for Veterans

 

 

L

 

Additional Classification and Secrecy Information

 

 

M

 

Biographical Sketches of Committee Members, Consultants, and Staff

 

 

1

Appendixes D-M can be found on a CD attached to the back of the report cover.

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
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Tables, Figures, and Boxes

TABLES

2-1

 

Categories of Arguments Favoring and Opposing Presumptions,

 

42

2-2

 

Presumptive Categories and Their Designated Health Outcomes,

 

43

3-1

 

Presumptions in VA’s Disability Program,

 

62

5-1

 

List of Case Studies (in chronological order of when presumptions were established by Congress or VA),

 

84

6-1

 

Possible Decisions About Service-Attributable Diseases (SADs) with Associated Errors and Losses,

 

142

6-2

 

Hypothetical Example of the Estimation of Service-Attributable Disease,

 

144

7-1

 

Hypothetical Example of Military Radiation Exposure, Smoking, and Cancer,

 

167

8-1

 

IOM Categorization from the Executive Summary of Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam,

 

185

8-2

 

IOM Categorization from the Executive Summary of Gulf War and Health, Volume 1: Depleted Uranium, Pyridostigmine Bromide, Sarin, Vaccines,

 

186

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9-1

 

Hypothetical Example of Risks from Multiple Causal Exposures,

 

209

9-2

 

Hypothetical PAFs Due to Smoking and Military Exposure,

 

210

9-3

 

True and False Positive and Negative Rates,

 

215

9-4

 

Comparing Sensitivity and Specificity of Two Hypothetical Sets of Compensation Criteria,

 

216

9-5

 

Hypothetical Scenario 1: PPV When AF = 50 Percent,

 

217

9-6

 

Hypothetical Scenario 2: PPV When AF = 9 Percent,

 

217

9-7

 

Hypothetical Scenario 3: PPV When AF = 2 Percent,

 

218

10-1

 

Timeline for Medical Surveillance and Exposure Data Collection,

 

242

10-2

 

Service-Specific Databases for Exposure,

 

257

10-3

 

Summary of VET Registry Projects,

 

267

10-4

 

National Academies’ and VA Medical Monographs on Veterans’ Health by Theater or Exposure,

 

268

10-5

 

VA Health Registries,

 

274

FIGURES

GS-1

 

Proposed framework for future presumptive disability decision-making process for veterans,

 

4

S-1

 

Roles of the participants involved in the presumptive disability decision-making process for veterans,

 

11

S-2

 

Proposed framework for future presumptive disability decision-making process for veterans,

 

17

3-1

 

Roles of the participants involved in the presumptive disability decision-making process for veterans,

 

53

6-1

 

Information gathering and its use in making general and specific compensation decisions,

 

139

7-1

 

Causal and spurious associations,

 

158

7-2

 

Scenario for causation without association,

 

158

7-3

 

The power of randomization,

 

161

7-4

 

Age as a confounder,

 

163

7-5

 

Unmeasured confounders,

 

163

7-6

 

TV and obesity,

 

163

7-7

 

Instrumental variable,

 

165

7-8

 

Rothman’s sufficient component causes model,

 

167

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8-1

 

Hypothetical illustrations,

 

179

8-2

 

Focusing on unmeasured confounders/covariates, or other sources of spurious association from bias,

 

180

8-3

 

IARC evaluation scheme,

 

184

8-4

 

Example posterior for Sufficient,

 

190

8-5

 

Example posterior for Equipoise and Above,

 

191

8-6

 

Example posterior for Below Equipoise,

 

192

8-7

 

Example posterior for Against,

 

193

9-1

 

Example of ROC curves,

 

219

9-2

 

“Economically rational” compensation plan, based on the attributable fraction,

 

225

9-3

 

Complete compensation (100 percent) for all exposed persons with disease, regardless of attributable fraction,

 

225

9-4

 

Complete compensation for all exposed persons only when attributable fraction is 50 percent or more,

 

226

9-5

 

Complete compensation for an AF of 50 percent or more, plus graduated compensation below 50 percent,

 

227

9-6

 

A rational process for determining veterans’ compensation,

 

228

10-1

 

Timeline for medical surveillance and exposure data collection,

 

241

10-2

 

DoD’s deployment health surveillance elements,

 

256

10-3

 

National Defense Occupational and Environmental Health Readiness System (DOEHRS),

 

258

12-1

 

Proposed framework for future presumptive disability decision-making process for veterans,

 

311

BOXES

3-1

 

Representatives at Each Tier of VA’s Internal Review of NAS Reports,

 

59

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Acronyms and Abbreviations

ACB Army Classification Battery

ACES-EM Automated Civil Engineering System-Environmental Management

ACHRE Advisory Committee on Human Radiation Experiments

ADA American Diabetes Association

AEC Atomic Energy Commission

AF Attributable fraction

AF-EMIS Air Force Environmental Management Information System

AFCESA Air Force Civil Engineer Support Agency

AFHLTA Armed Forces Health Longitudinal Technology Application

AFHS Air Force Health Study

AFHSC Armed Forces Health Surveillance Center

AHA American Heart Association

AHLTA Armed Forces Health Longitudinal Technology Application

AhR Aryl hydrocarbon receptor

AIDS Acquired immunodeficiency syndrome

AIS Automated information systems

ALS Amyotrophic lateral sclerosis (Lou Gehrig’s disease)

AML Acute myelogenous leukemia

ANG Air National Guard

ANLL Acute non-lymphocytic leukemia

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APIMS Air Program Information Management System

AS Assigned share

ASTM American Society for Testing and Materials

ATSDR Agency for Toxic Substances and Disease Registry

BEIR Biological Effects of Ionizing Radiation

BMI Body mass index

C&P Service Compensation and Pension Service

CCB Configuration Control Board

CCS Command Core System (Air Force)

CDC Centers for Disease Control and Prevention

CDVA Commonwealth Department of Veterans’ Affairs

CERHR Center for the Evaluation of Risks to Human Reproduction

CES-D Centers for Epidemiological Studies-Depression Scale

CFR Code of Federal Regulations

CHD Coronary heart disease

CHF Congestive heart failure

CHPPM Center for Health Promotion and Preventive Medicine (Army)

CI Confidence interval

CIA Central Intelligence Agency

CIRRPC Committee on Interagency Radiation Research and Policy Coordination

CLL Chronic lymphocytic leukemia

CNS Central nervous system

COPD Chronic obstructive pulmonary disease

CRDP Concurrent Retirement and Disability Payments

CRS Congressional Research Service

CRSC Combat-Related Special Compensation

CSM Cerebrospinal malformation

CSP Cooperative Studies Program

CVD Cardiovascular disease

DALY Disability-adjusted life year

DCI SCI Director of Central Intelligence Sensitive Compartmented Information Programs

DECC-D Defense Enterprise Computing Center-Detachment

DHHS Department of Health and Human Services

DISA Defense Information Systems Agency

DMDC Defense Manpower Data Center

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DMSS Defense Medical Surveillance System

DNBI Disease and nonbattle injury

DoA Department of the Army

DoD Department of Defense

DoDI Department of Defense Instruction

DOE Department of Energy

DOEHRS Defense Occupational and Environmental Health Readiness System

DoL Department of Labor

DSM-III-R Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised

DTAS Defense Theater Accountability Software

EA Exposure Assessment

EAR Excess absolute risk

EEOICPA Energy Employees Occupational Illness Compensation Program Act

EESOH-MIS Enterprise Environmental Safety and Occupational Health-Management Information System

EO Executive Order

EPA Environmental Protection Agency

EPCRA Emergency Planning and Community Right-to-Know Act

ERIC Epidemiologic Research and Information Center

ERR Excess relative risk

FECA Federal Employees’ Compensation Act

FERS Federal Employees Retirement System

FHIE Federal Health Information Exchange

FHP Force Health Protection

fMRI Functional magnetic resonance imaging

FN False negative

FNR False negative rate

FOUO For official use only

FP False positive

FPR False positive rate

FR Federal Register

FY Fiscal Year

GAF Global Assessment of Functioning

GAO Government Accountability Office

GBD General birth defect

GBS Guillain-Barre syndrome

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GPS Global Positioning System

GT test General Technical test

GW Gulf War

Gy Gray (measure of dose of irradiation)

HART Health Assessment Review Tool

HCFA Health Care Financing Administration

HEW U.S. Department of Health, Education, and Welfare

HHIM Health Hazard Information Module

HIV Human immunodeficiency virus

HMMS Hazardous Materials Management System

HUS Hemolytic-uremic syndrome

IARC International Agency for Research on Cancer

ICD International Classification of Diseases

IH Industrial hygiene

IHIMS Industrial Hygiene Information Management System (Navy)

IOM Institute of Medicine

IQ Intelligence quotient

IREP Interactive RadioEpidemiological Program

IU Individual unemployability

LIMDIS Limited Dissemination

LMF Lovelace Medical Foundation

MDS Myelodysplastic syndrome

MFUA Medical Follow-up Agency

MMPI Minnesota Multiphasic Personality Inventory

MOA Memorandum of Agreement

MOS Military occupational specialty

MRI Magnetic resonance imaging

MS Multiple sclerosis

MTF Military Treatment Facility

NAS National Academy of Sciences

NCEH National Center for Environmental Health

NCHS National Center for Health Statistics

NCI National Cancer Institute

NEHC Navy Environmental Health Center

NESHAP National Emission Standards for Hazardous Air Pollutants

NHANES National Health and Nutrition Examination Survey

NHL Non-Hodgkin’s lymphoma

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NHLBI National Heart, Lung, and Blood Institute

NHS Nurses Health Study

NIH National Institutes of Health

NIOSH National Institute for Occupational Safety and Health

NOCONTRACT Not releasable to contractors

NOED Navy Occupational Exposure Database

NOFORN Not releasable to foreign nationals

NPV Negative predictive value

NRC National Research Council

NTP National Toxicology Program

NTS Nevada Test Site

OEF Operation Enduring Freedom

OEH Occupational and environmental health

OEHHA Office of Environmental Health Hazard Assessment

OEHS Occupational environmental health and safety

OEL Occupational exposure limit

OGC Office of the General Counsel

OH Occupational health

OHMIS Occupational Health Management Information System

OIF Operation Iraqi Freedom

OMB Office of Management and Budget

OPHEH Office of Public Health and Environmental Hazards

OPM Office of Personnel Management

OR Odds ratio

ORCON Originator controlled dissemination and extraction of information

ORD Office of Research and Development

OSHA Occupational Safety and Health Administration

OSTP Office of Science and Technology Policy

PAF Population attributable fraction

PAR Population attributable risk

PC Probability of causation

PCB Polychlorinated biphenyl

PDDM Presumptive disability decision making

PHA Periodic health assessment

PKDL Post-kala-azar dermal leishmaniasis

PL Public Law

POM Program Objectives Memorandum

POW Prisoner of War

PPB Parts per billion

PPG Pacific Proving Grounds

Suggested Citation:"Front Matter." Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press. doi: 10.17226/11908.
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PPM Parts per million

PPV Positive predictive value

PSA Prostate-specific antigen

PSG II Professional Staffing Group II

PTF Presidential Task Force

PTSD Posttraumatic stress disorder

PY Person-year

RADS Reactive airways dysfunction syndrome

RCT Randomized controlled/clinical trial

RD Restricted data

ReA Reactive arthritis

RECA Radiation Exposure Compensation Act of 1990

RECAC Radiation Exposure Compensation Act Committee

REVCA Radiation-Exposed Veterans Compensation Act

RO Rey-Osterreith Test

ROC Receiver Operator Characteristics curve

RR Relative risk/risk ratio

RTI Research Triangle Institute

SAD Service-attributable disease

SAF Service-attributable fraction

SANG Saudi Arabian National Guard

SAP Special Access Program

SCI Sensitive Compartmented Information

SCID Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders

SCL Symptoms Checklist

SEER Surveillance Epidemiology and End Results

SEG Similar exposure group

SES Socioeconomic status

SF Standard Form

SFFWG Shared Functions Focus Working Group

SHAD Project Shipboard Hazard and Defense

SMITREC Serious Mental Illness Treatment Research and Evaluation Center

SMR Standardized mortality ratio

SSA Social Security Administration

SSDI Social Security Disability Insurance

SSI Supplemental Security Income

TBI Traumatic brain injury

TCDD Tetrachlorodibenzo-p-dioxin

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TN True negative

TNR True negative rate

TP True positive

TPR True positive rate

UNSCEAR United Nations Scientific Committee on the Effects of Atomic Radiation

USC United States Code

USPSTF U.S. Preventive Health Services Task Force

VA Department of Veterans Affairs

VAO Veterans and Agent Orange

VASRD Veterans Administration Schedule for Rating Disabilities

VBA Veterans Benefits Administration

VDBC Veterans’ Disability Benefits Commission

VDRECSA Veterans’ Dioxin and Radiation Exposure Compensation Standards Act

VES Vietnam Experience Study

VET (registry) Vietnam Era Twin (registry)

VHA Veterans Health Administration

VHI Veterans Health Initiative

VISTA Veterans Health Information Systems and Technology Architecture

VOC Volatile organic compound

VSO Veterans Service Organization

WAIS-R Wechsler Adult Intelligence Scale-Revised

WNINTEL Warning notice, intelligence sources, and methods involved

WRIISC War-Related Illness and Injury Study Centers

WWI World War I

WWII World War II

YLD Years of life lived with disability

YLL Years of life lost

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The United States has long recognized and honored the service and sacrifices of its military and veterans. Veterans who have been injured by their service (whether their injury appears during service or afterwards) are owed appropriate health care and disability compensation. For some medical conditions that develop after military service, the scientific information needed to connect the health conditions to the circumstances of service may be incomplete. When information is incomplete, Congress or the Department of Veterans Affairs (VA) may need to make a "presumption" of service connection so that a group of veterans can be appropriately compensated.

The missing information may be about the specific exposures of the veterans, or there may be incomplete scientific evidence as to whether an exposure during service causes the health condition of concern. For example, when the exposures of military personnel in Vietnam to Agent Orange could not be clearly documented, a presumption was established that all those who set foot on Vietnam soil were exposed to Agent Orange. The Institute of Medicine (IOM) Committee was charged with reviewing and describing how presumptions have been made in the past and, if needed, to make recommendations for an improved scientific framework that could be used in the future for determining if a presumption should be made. The Committee was asked to consider and describe the processes of all participants in the current presumptive disability decision-making process for veterans. The Committee was not asked to offer an opinion about past presumptive decisions or to suggest specific future presumptions.

The Committee heard from a range of groups that figure into this decision-making process, including past and present staffers from Congress, the VA, the IOM, veterans service organizations, and individual veterans. The Department of Defense (DoD) briefed the Committee about its current activities and plans to better track the exposures and health conditions of military personnel. The Committee further documented the current process by developing case studies around exposures and health conditions for which presumptions had been made. Improving the Presumptive Disability Decision-Making Process for Veterans explains recommendations made by the committee general methods by which scientists, as well as government and other organizations, evaluate scientific evidence in order to determine if a specific exposure causes a health condition.

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