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24 EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSL4N
GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM
diligent efforts to unmask occult medical problems that could substantially
contribute to fatigue have been productive and should continue.
USE OF THE CCEP RESULTS FOR EDUCATION, IMPROVEMENTS
IN THE MEDICAL PROTOCOL, AND OUTCOME EVALUATIONS
The results of the CCEP can be used for several purposes, including to
educate Persian Gulf veterans and the physicians caring for them, to improve the
medical protocol itself, and to evaluate patient outcomes. In addition, the early
progress of SCC should be evaluated so that its successful elements can be
disseminated to other hospitals involved in the CCEP.
Use of the CCEP Results for Education
The results of the CCEP should provide valuable information to Persian
Gulf veterans and the physicians who are caring for them. The IOM committee
encourages the DoD to continue to release its analysis of the results of the
CCEP on an ongoing, periodic basis. Several audiences that would be interested
in these results include active-duty members of the service, veterans, members
of the U.S. Congress, the lay media, as well as military, DVA, and civilian
medical and public health professionals.
The medical findings of the CCEP should be distributed promptly to all
primary care physicians at the MTFs and RMCs. This would provide feedback
on their diagnostic decision-making. Information on the frequencies of
particular symptoms and their specific diagnoses made in the CCEP population
could be useful, for instance, in developing a differential diagnosis for individual
patients. The CCEP medical findings would also be of interest to physicians
in the DVA system and in the general community. Almost 500,000 of the
700,000 Persian Gulf veterans had been discharged from active duty as of mid-
1995; therefore, they are currently seeking health care from DVA or from
community-based physicians, rather than from the DoD.
A more concise version of the DoD report on 10,020 patients, written in
nontechnical language and with clearly stated conclusions, should be developed
for a target audience of active-duty service personnel and veterans. These
individuals have the greatest need to understand the results of the CCEP and
how to interpret them. Currently, many active-duty military personnel and
veterans seem to receive much of their information about the CCEP through the
lay media. If the DoD developed and distributed a fact sheet or newsletter
aimed at Persian Gulf veterans, the information on the CCEP would be more
accurate and more comprehensive than most reports in the general news media.
This would also provide an additional opportunity to notify the readers about the
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EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN 25
GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM
availability of the medical exam in the CCEP, the hotline number, and the
eligibility criteria.
The DoD should also consider developing for clinical use in the CCEP a
more comprehensive document that describes the many potential exposures in
more detail. Patients frequently ask their physicians about what they were
exposed to, and if the CCEP physicians could obtain a clearer picture of the
possible range of exposures, they might be able to counsel their patients more
effectively. Any document that is prepared, however, must make clear what is
known and what is unknown about the relationship between these stressors and
the physical or psychological consequences. The DoD report on 10,020 CCEP
patients and several other recent reports have also outlined the potential physical,
chemical, biological, and psychological stressors in the Persian Gulf War
(Defense Science Board, 1994; NIH, 1994; IOM, 1995b; DoD, l995d; PGVCB,
l995a,b). Even though these reports overlap, most are not comprehensive or
designed for clinical use.
Use of the CCEP Results to Improve the
Medical Protocol
The DoD now has results on the examinations of more than 10,000 CCEP
patients. These results could be used to improve the standardized
questionnaires, lab tests, and specialty consultations. Three examples are
provided here, but other beneficial revisions to the protocol are certainly
possible.
Some data on potential psychological stressors of the war are available
(Sutker et al., 1993, 1994a,b; Wolfe et al., 1993~. More refined questions
related to these stressors could be added systematically to the Phase I medical
history. The CCEP physicians might find this information useful in diagnosing
and counseling their patients. In addition, it may be possible to identify patients
who are at increased risk of psychological problems on the basis of their
experiences in the war. For example, it has already been recognized that direct
combat exposure is a risk factor for developing a psychiatric disease. In
addition, recent studies have demonstrated that exposure to death- that is,
viewing or having to bury dead Iraqi soldiers—is also a risk factor (Sutker et
al., 1994a,b). Perhaps explicit questions on death exposure and other known
risk factors could be added to the Phase I questionnaire.
The CCEP results should be analyzed to determine whether there are lab
tests or specialty consultations that should be added systematically to Phase I to
increase its diagnostic yield. Among the first 10,020 CCEP patients, about
8,300 completed their evaluations in Phase I and about 1,700 completed their
evaluations in Phase II (DoD, l995d). Diseases that are diagnosed relatively
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26 EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN
GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM
frequently in Phase II may often be overlooked in Phase I. If such diseases
could be identified, perhaps appropriate screening instruments could be added
to Phase I. A hypothetical example is depression, which has been diagnosed in
11% of the 10,020 patients (DoD, l995d). If the recognition of this disease has
occurred predominantly during Phase II, then perhaps a screening questionnaire
for it could be added systematically in Phase I for use by primary care
. .
P 1yslclans.
The DVA uses a protocol similar to that used in the CCEP called the
Uniform Case Assessment Protocol (UCAP). The methods and clinical results
of the CCEP and UCAP should be compared to coordinate and improve the two
programs.
Use of the CCEP Results for Patient Outcome Evaluations
On the basis of more than 10,000 patient evaluations to date, RMC
physicians could begin to perform a series of targeted patient evaluations. The
most common diseases in the CCEP could be identified, and suggested
approaches to patient treatment could be developed. Consensus guidelines for
the treatment and counseling of CCEP patients who have the most common
disorders could be useful for primary care physicians. Depression is a common
disease that most CCEP physicians are likely to encounter.
If one RMC has had a lot of experience with a particular disease category
and some measure of success in its treatment, the DoD could ensure that a
description of their successful methods is communicated to the other MTFs and
RMCs across the country. For example, Walter Reed Army Medical Center had
performed more than 500 Phase II evaluations by mid-1995, all of which
included psychiatric evaluations (Roy, 19951. Walter Reed physicians have
diagnosed debilitating psychiatric diseases in a high proportion of these patients.
If Walter Reed staff have identified the elements of a psychiatric treatment
program that are particularly effective or ineffective in a military population, a
summary of these elements could be shared among the CCEP physicians
nationwide.
Another potential candidate for outcome evaluation could be an investigation
of the types of CCEP patients who apply for a medical discharge from the
military. The DoD could perform a review of the types and severities of the
disorders among CCEP patients who have applied for disability payments or for
medical discharge from the service. In addition, the final disposition of these
cases could be evaluated, including the potential relationship between particular
diseases and Persian Gulf service. The DoD could use the results of these
disability determinations to predict which diseases are likely to be associated
with the most impairment among CCEP patients in the future. The DoD could
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EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN 27
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also use these results to develop rehabilitation and early intervention methods for
impaired Persian Gulf veterans, such as the SCC, which is described below.
Another reason to analyze these disability claims would be to investigate possible
preexisting risk factors for the development of the impairment. If such risk
factors are identifiable, then targeted preventive medicine interventions could be
planned for individuals participating in future overseas deployments.
Specialized Care Center
Overview of the Goals, Structure, and Early Progress of the SCC
On June 9, 1995, the IOM committee made a site visit to the SSC at the
Walter Reed Army Medical Center. Presentations were given by three of the
SCC staff who have developed and implemented the program. In addition, the
committee interviewed 4 of the first 10 patients who graduated from the SCC.
This brief description of the SCC and the committee's comments on the program
arise primarily from information gathered at the site visit.
The SCC was developed in response to a need for "further treatment and
diagnosis for conditions possibly related to environmental and/or psychosocial
stressors associated with deployment" (Roy, 19951. Pain treatment centers were
used as the model for development of the SCC. The first group of six patients
entered the SCC system on March 22, 1995. The three major SCC referral
criteria are (1) symptoms without a clear diagnosis; (2) symptoms out of
proportion to the diagnosis; or (3) a diagnosis of somatoform disorder, chronic
fatigue syndrome, multiple chemical sensitivity, f~bromyalgia, or PTSD. In
addition, the patients should be unable to meet weight or fitness standards or
show other signs of significant impairment.
The SCC is a very structured 3-week inpatient program that incorporates
rigorous physical training and intensive mental health components. The main
goals of the SCC are to refocus individual patients from illness to wellness and
to return participants to full duty within 6 months. The SCC participants are
required to sign a contract stating that they will participate 100% in all activities
and refrain from interference in the efforts of other patients or they will be
subject to termination from the program. A follow-up visit after 6 months is
planned for each graduate at Walter Reed.
The first 15 SCC patients were all enlisted men, with a mean age of 35
years (range of 24-58 years) (Roy, 19951. All of the first 15 SCC patients
reported 10 or more somatic symptoms at entry.
The SCC program does have several limitations, including a low referral
rate by CCEP physicians, a low enrollment rate, and uncertainty about the
availability of follow-up care, which may result in regression (Roy, 1995~. For
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28 EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN
GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM
the first 2 months of the SCC, 50% of the referred patients declined enrollment.
If a candidate for the SCC was in the reserves, it was difficult to leave a civilian
job for 3 weeks or longer. Some active-duty personnel declined participation
because they had already gone through the disability process and they were
separating from the service.
The SCC staff are concerned about the effect that lack of follow-up will
have on any progress made during the SCC program. Many MTFs have only
one psychiatrist and one social worker, and these personnel already have very
heavy workloads (Follansbee, 1995~. At the time of discharge from Walter
Reed, there is an effort to link the patient to a physician, chaplain, or social
worker who can provide follow-up care at the local MTF.
Four of the first 10 SCC graduates were briefly interviewed by the IOM
committee. All four stated they were very satisfied with the care that they had
received in the SCC. All reported greatly improved health and outlook on life.
These four SCC patients did express concern about the accessibility of high-
quality follow-up care. They stated that if they developed a sudden worsening
of symptoms, they would want to return to Walter Reed for treatment, even
though they all lived at least several hundred miles away. They were concerned
that they could not expect to receive timely, high-quality medical care from an
empathetic physician at an MTF.
Committee Comments on the Goals, Structure, and
Early Progress of the SSC
The IOM committee concludes that the DoD has made serious efforts to
develop an SCC program that has ambitious goals for a select group of seriously
impaired military personnel. The committee's review should be considered
preliminary, however, because it is based on one visit and it is still early in the
development of the program.
The SCC currently performs a thorough reevaluation of each patient's
medical problems. SCC physicians should consider limiting the diagnostic role
that they play to focusing on the incoming patients who have been very difficult
to diagnose at the RMC level. Instead, the SCC should focus on providing
multidisciplinary treatment modalities that are not readily available at the RMC
level.
The need for individualized follow-up is crucial for the types of difficult
patients who are likely to be treated at the SCC. Medical staff at the SCC will
need to know whether a particular therapeutic plan is feasible at the patient's
nearest MTF and whether long-term follow-up care can be performed. The
primary care physician at the MTF needs to encourage continuous patient
compliance with the carefully designed, individualized therapeutic regimens.
Representative terms from entire chapter:
blinking rate
