3
The Comprehensive Clinical Evaluation Program*

OVERVIEW

In June 1994, DoD instituted the CCEP to provide a thorough, systematic clinical evaluation program for the diagnosis and treatment of Persian Gulf veterans at military facilities in the US and overseas.

The CCEP was designed to (1) strengthen the coordination between DoD and the VA; (2) streamline patient access to medical care; (3) make clinical diagnoses in order to treat patients; (4) provide a standardized, staged evaluation and treatment program; and (5) assess possible Gulf War-related conditions. (Veterans who have left military service entirely are eligible for evaluations from the VA; personnel still on active duty, in the Reserves, or in the National Guard may request medical evaluations from DoD.) Phase I of the CCEP consists of a medical history, physical examinations, and laboratory tests. These are comparable in scope and thoroughness to an evaluation conducted during an inpatient internal medicine hospital admission (see Appendix H). All CCEP participants are evaluated by a primary care physician at their local medical treatment facility and receive specialty consultations if these are deemed appropriate by their primary care physician. Evaluation at this phase includes a survey for nonspecific patient symptoms, including fatigue, joint pain, diarrhea, difficulty concentrating, memory and sleep disturbances, and rashes.

*  

The material in this section is based, in part, on presentations and discussion by Lt. Col. Tim Cooper, M.D., MAJ Charles Engel, M.D., COL Kurt Kroenke, M.D., MAJ Charles Magruder, M.D., and MAJ Michael Roy, M.D.



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--> 3 The Comprehensive Clinical Evaluation Program* OVERVIEW In June 1994, DoD instituted the CCEP to provide a thorough, systematic clinical evaluation program for the diagnosis and treatment of Persian Gulf veterans at military facilities in the US and overseas. The CCEP was designed to (1) strengthen the coordination between DoD and the VA; (2) streamline patient access to medical care; (3) make clinical diagnoses in order to treat patients; (4) provide a standardized, staged evaluation and treatment program; and (5) assess possible Gulf War-related conditions. (Veterans who have left military service entirely are eligible for evaluations from the VA; personnel still on active duty, in the Reserves, or in the National Guard may request medical evaluations from DoD.) Phase I of the CCEP consists of a medical history, physical examinations, and laboratory tests. These are comparable in scope and thoroughness to an evaluation conducted during an inpatient internal medicine hospital admission (see Appendix H). All CCEP participants are evaluated by a primary care physician at their local medical treatment facility and receive specialty consultations if these are deemed appropriate by their primary care physician. Evaluation at this phase includes a survey for nonspecific patient symptoms, including fatigue, joint pain, diarrhea, difficulty concentrating, memory and sleep disturbances, and rashes. *   The material in this section is based, in part, on presentations and discussion by Lt. Col. Tim Cooper, M.D., MAJ Charles Engel, M.D., COL Kurt Kroenke, M.D., MAJ Charles Magruder, M.D., and MAJ Michael Roy, M.D.

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--> The primary care physician may refer patients to Phase II for further specialty consultations if he or she determines that it is clinically indicated. These Phase II evaluations are conducted at a regional medical center and consist of targeted, symptom-specific examinations, lab tests, and consultations. During this phase, the potential causes of unexplained illnesses are assessed, including infectious agents, environmental exposures, social and psychological factors, and vaccines or other protective agents. Both Phase I and Phase II are intended to be thorough for each individual patient and to be consistent among patients. Every medical treatment facility has a designated CCEP physician coordinator who is a board-certified family practitioner or internal medicine specialist. The coordinator is responsible for overseeing both the comprehensiveness and the quality of Phase I exams. At regional medical centers, CCEP activities are coordinated by board-certified internal medicine specialists who also oversee program operations of the medical treatment facilities in their region. In March 1995, DoD established the Specialized Care Center at Walter Reed Army Medical Center to provide additional evaluation, treatment, and rehabilitation for patients who are suffering from chronic debilitating symptoms. Seventy-eight patients have gone through the Specialized Care Program, which consists of an intensive 3-week evaluation and treatment protocol designed to improve their health status. The Specialized Care Center has three teams that overlap: (1) the physical team (physiatrist, physical therapist, occupational therapist, fitness trainer); (2) the medical team (internist, physiatrist, specialists, nutritionist); and (3) the psychosocial team (psychologist, social worker, wellness coordinator). Physical training, individualized to the patient, is an important part of the program, as is education. The program works with the patient on issues that result in dysfunction or impairment. The focus is not on the cause of the problems, but rather on how the patient can get better. SIGNS, SYMPTOMS, AND ILL-DEFINED CONDITIONS (SSID) The Department of Defense reported to the committee that approximately 17% of the 21,579 patients in the CCEP had a primary diagnosis of SSID, while about 42% had ''any diagnosis" of SSID. The subcategories of SSID are symptoms, nonspecific abnormal findings, and ill-defined and unknown causes of morbidity and mortality. Of the patients with SSID, 96.6% (3,591 patients) of the diagnoses were in the symptom subcategory, 3% (112) in the nonspecific abnormal finding subcategory, and 0.4% (16) in the remaining subcategory (Table 3.1).

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--> TABLE 3.1 Diagnoses Within the Symptom Group (percentage) Symptom Primary Diagnosis Any Diagnosis Fatigue 27 30 Sleep disturbance 18 24 Headache 14 21 Memory loss 10 16 Chest pain 5 7 Rash 4 5 DoD reported that a comparison of patients in the diagnostic categories of primary SSID, any SSID, non-SSID, and healthy found essentially no differences in percentages of males and females, no significant age differences, and no significant ethnic differences. For branch of service, the Marines are slightly more represented in the non-SSID population. In a comparison of active-duty versus reserve status, the active duty are slightly more likely to be in the non-SSID diagnostic category, whereas the reserves are slightly more likely to be in an SSID category (Table 3.2). TABLE 3.2 Most Common Primary SSID Diagnosis by Phase of CCEP (percentage) Symptom Phase I Phase II Fatigue 28 18.0 Sleep disturbance 17 37.5 Headache 14 17.0 Memory loss 10 6.5 Chest pain 5 2.5 Rash 4 1.5 Of the 21,579 patients seen in Phase I, 4,012 (18.6%) initially received an SSID diagnosis. Of these, 703 (17.5%) were referred to Phase II; only 239 (34%) of this group continued to be diagnosed with SSID, whereas 464 (66%) received an alternative diagnosis that did not include SSID. About 40% of these changed to a primary diagnosis within the psychological category. However, 3,309 patients who received an SSID diagnosis at Phase I were not referred to Phase II. Of the 17,567 patients who did not receive a diagnosis of SSID, 1,603 were referred for a Phase II exam. Of these, 171 received an SSID diagnosis, whereas 1,432 had no SSID diagnosis assigned. In summary, DoD reported no demographic differences between SSID and non-SSID patients; fatigue is the

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--> most common chief complaint in SSID patients; joint pain is the most common chief complaint in non-SSID patients; the most common primary SSID diagnosis differs by phase; and a diagnosis of primary SSID made in Phase I is commonly changed in Phase II. CHRONIC FATIGUE SYNDROME (CFS) AND FIBROMYALGIA IN THE CCEP POPULATION The Centers for Disease Control and Prevention (CDC) consensus definition for CFS and the American College of Rheumatology (ACR) definition of fibromyalgia were communicated to all medical treatment facilities in March 1995. Those performing Phase I and Phase II examinations were encouraged to use these definitions. Of the total population seen in the CCEP, 12.4%, or 3,078, individuals received any diagnosis of fatigue (ICD-9 780.7). A primary diagnosis of fatigue was given to 4.5%, or 1,120 individuals. Of the 1,120 individuals receiving a primary diagnosis of fatigue, 48 (4%) were diagnosed with CFS, 8 (1%) with idiopathic chronic fatigue, 242 (22%) with chronic fatigue, and 822 (73%) with fatigue. If secondary diagnoses are included, a total of 74 individuals received a diagnosis of CFS. Thus, CFS was diagnosed in 2.4% of the population who received any diagnosis of fatigue but only in 0.3% of the total 24, 823 1 CCEP participants. The prevalence of CFS in the general population ranges from 0.007% to 0.037%; in medical clinics, from 0.13% to 0.3%, and in fatigue clinics it is 5.0%. For fibromyalgia, according to the ACR definition, of the 24,823 CCEP participants, 141 (0.57%) had a primary diagnosis of fibromyalgia and an additional 177 (0.71%) had any secondary diagnosis of fibromyalgia. For the total number (318) of patients with either a primary or a secondary diagnosis of fibromyalgia, the number of patients with the comorbid diagnoses are shown in Table 3.3. 1   Individuals within DoD conducted analyses of CCEP data based on committee requests for information; therefore, these analyses were performed at different times. As a result, the total number of CCEP participants varied. Analysis of SSID was conducted on a total CCEP population of 21,579 patients, whereas analysis of CFS and fibromyalgia included 24,823 CCEP participants. Since the committee focused not on numbers of cases but rather on general patterns, members did not feel it was necessary to ask for updated figures.

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--> TABLE 3.3 Number of Comorbid Diagnoses in Patients with Primary or Secondary Diagnosis of Fibromyalgia Irritable bowel syndrome 57 (17.9%) Tension headaches 44 (13.8%) Sleep disturbances 65 (20.4%) Depression 77 (24.2%) Posttraumatic stress disorder 54 (17.0%) Table 3.4 shows the symptoms associated with CFS and fibromyalgia. The first column lists the symptom; the CCEP column refers to the percentage of CCEP patients complaining of that symptom; the fibromyalgia and CFS columns represent percentages of patients diagnosed with these conditions who complain of that symptom. TABLE 3.4 Percentage of Patients Diagnosed with the Condition They Complain About symptom CCEP (%) Fibro (%) CFS (%) Difficulty concentrating 26.8 53.8 59.5 Headache 39.6 60.4 55.4 Joint pain 51.2 76.4 68.9 Memory deficit 34.6 59.7 62.2 Muscle pain 21.8 62.3 44.6 Sleep disturbance 33.6 60.7 52.7 Abdominal pain 16.4 36.2 28.4 Bleeding gums 8.5 18.6 12.2 Depression 22.1 46.9 45.9 Diarrhea 22.1 46.9 45.9 Hair loss 12.5 17.9 14.9 Rash 29.9 40.6 50.0 Dyspnea 19.2 29.9 32.4 STRESS AND PSYCHIATRIC DISORDERS Patients who are referred to Phase II are much more likely to receive a psychological diagnosis than those who are diagnosed in Phase 1. It is also the case that psychological diagnoses seem to be more common in the enlisted population. In looking at the prevalence of psychological diagnoses, whether primary or secondary, somatoform disorders account for 14.3% and mood disorders for 12.8%. The prevalence of posttraumatic stress disorder (PTSD) is 5.5%; anxiety disorders, 3.2%; substance abuse, 4.2%; and other psychological diagnoses, 8.5%.

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--> Mood disorders and PTSD are almost equally likely to be primary or secondary, whereas somatoform disorders, substance abuse, and other anxiety disorders are much more likely to be secondary diagnoses. In examining the distribution of primary psychological diagnoses over time, it has been found that depression increased from about one-third of the diagnoses in the last half of 1994 to almost 50% of the primary psychological diagnoses in the last half of 1996, with the greatest portion of this increase occurring in the last 6 months. Depression is also more common among older patients. Women are more likely to be diagnosed with somatoform and mood disorders, whereas PTSD and substance abuse are more common among men. In terms of duty status, mood disorders and PTSD tend to be more common among guards or reservists and retired participants than among those on active duty, whereas somatoform disorders are more common among the active-duty population (Table 3.5). If tension headache is included as a somatoform disorder, it is by far the most common at 19.4% of the 24.6% with a primary diagnosis of somatoform disorder. For those with a primary diagnosis of substance abuse, the most common disorder is generally alcohol misuse followed by misuse of tobacco. Any other substance abuse problems were distinctly rare, with only 4 individuals (0.1%) in this category. For those in the category of primary other psychiatric diagnosis, 7.9% are adjustment disorders and 3.7% organic mental disorders (Note: some of these are reported as actually being psychosis due to alcohol or substance abuse); sleep disorders represent 3.2%; schizophrenia or unspecified psychosis amount to 0.2%, and other disorders constitute 2.5%. For the 7,564 individuals who received a secondary psychiatric diagnosis, the most common diagnosis was somatoform disorders (39.2%) followed by mood disorders (26.9%), substance abuse (14.1%), PTSD (11%), anxiety disorders (8.9%), and other psychiatric disorders (22.1%). Since it is important to examine comorbidity, patients in the CCEP have a coded primary diagnosis and up to six additional diagnoses. For CCEP patients with a primary psychiatric diagnosis, the comorbidity of other diagnoses (second to seventh) are found in Table 3.6. An examination of only the second diagnosis for comorbidity with a primary psychiatric diagnosis reveals that psychological disorders are the most common at 18.0%, followed by musculoskeletal disorders at 11.1%, ill-defined conditions at 8.2%, digestive diseases at 6.0%, neurological disorders at 4.3%, skin diseases at 3.7%, respiratory diseases at 2.9%, infectious diseases at 1.9%, and neoplasms at 0.6%.

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--> TABLE 3.5 Distribution of Diagnoses for the 4,304 Patients Receiving a Primary Psychiatric Diagnosis Diagnosis Percentage No. of Patients Mood disorders 34.0 1,461 Somatoform disorders 24.4 1,059 PTSD 14.9 640 Anxiety disorders 5.5 237 Substance abuse 3.5 152 Other diagnoses 17.5 755 Mood disorders can be broken into the following categories: Other depressive syndromes 16.0 715 Major depression 8.9 838 Dysthymia 7.4 319 Bipolar disorder 0.7 30 Other mood disorders 0.3 14 TABLE 3.6 Comorbidity of Other Diagnoses for Patients with Primary Psychiatric Diagnosis Diagnosis Percentage No. of Patients Psychological disorders 40.1 1,735 Neurological disorders 17.1 740 Musculoskeletal disorders 48.4 2,091 Ill-defined conditions 32.9 1,422 Digestive diseases 23.0 995 Skin diseases 17.6 762 Respiratory diseases 13.8 596 Infectious diseases 8.2 356 Neoplasms 2.4 104

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