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EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM IMPLEMENTATION OF THE CCEP 7 Two areas that are involved with the implementation of the CCEP deserve attention. These are (1) referrals of patients from Phase I to Phase II, and (2) systematic guidelines for psychiatric referrals and the adequacy of psychiatric resources. Referrals of Patients from Phase I to Phase II of the CCEP At the time of the first committee meeting in October 1994, approximately 9,000 patients were registered in the CCEP, and the number was growing at the rate of more than 1,000 per month (IOM, 1994~. Only about 20% of the patients were receiving a specific diagnosis in Phase I at the MTF level. About 80% of the patients were being referred to Phase II at the RMC level for the completion of their medical evaluations. This large patient load threatened to overwhelm the capacities of the RMCs. Several relevant suggestions on the administration of the CCEP were made in the first IOM report, as follows: One proposal that has emerged to deal with the large number of patients in the CCEP is to structure and revise the CCEP protocol and logistics so that a majority of patients would receive a final diagnosis by the staff of local MTFs in Phase I of the CCEP. Currently the majority of patients do not receive a final diagnosis until Phase II, yet some of these patients have straightforward medical problems such as migraine headaches or rheumatoid arthritis. If more diagnostic resources could be marshalled in Phase I, then perhaps many more final diagnoses could be reached at this stage. This major change would require the availability of substantial numbers of internists or family practitioners at MTFs to perform comprehensive evaluations. It would also require better, more consistent explanations to MTF physicians about the purposes and procedures of the CCEP. It would require regional medical center physicians to provide adequate quality assurance of MTF work-ups and timely feedback to MTF providers.... Another option is to curtail diagnostic work-ups in patients with minor complaints, and who are not seriously disabled. Currently, patients who do not accept their initial diagnosis (for example, tension headaches or irritable bowel syndrome) can request a continued evaluation all the way through Phase II of the examination. Alternatively, it has been suggested that if a physician has made a

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8 EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM definitive diagnosis and appropriate treatment has been given, the evaluation would be concluded (IOM, 1994, pay. All of the committee's suggestions have subsequently been incorporated into the CCEP. On January 17, 1995, the DoD implemented several changes in the administrative procedures of the CCEP protocol (DoD, 1995a). In particular, the DoD set a goal that about 80% of patients would receive a definitive diagnosis at an MTF level and that only 20 % would be referred to the RMC level (DoD, 1995a). For some patients, this change has required specialty consultations at the MTF, such as psychiatry or rheumatology, as well as advice from an RMC physician. These changes necessitated an enhanced quality control role by the RMC physician and prompt, appropriate feedback to the MTF physician. Another major change was that referral to Phase II was made on the basis of the clinical judgment of the primary care physician, and patients were no longer permitted to self-refer to an RMC. These changes have improved the timeliness of patient scheduling and have reduced the backlog of patients waiting for the initiation or completion of their evaluations. Before February 1995, 28% of the CCEP patients were referred to an RMC; after that date, 4% were referred. Altogether, 83% of the first 10,020 CCEP evaluations were completed at Phase I and 17% were completed at Phase II (DoD, 1995c). The IOM committee encourages these efforts to provide more care at the primary care level, because they will enhance the continuity of care and will foster the establishment of an ongoing therapeutic relationship. There is a subgroup of patients whose illnesses are difficult to diagnose and who should continue to be referred to Phase II at an RMC. The IOM committee believes that it is appropriate that the decision to refer to Phase II should be based on the clinical judgment of the primary care physician, which, in turn, would be dependent on the clarity of the patient's diagnoses and the feasibility of the proposed treatment program at the MTF level. The committee supports the DoD's goal of enhanced accessibility of RMC physicians to allow regular consultations with MTF primary care physicians on patients with more complex diagnoses. Systematic Guidelines for Psychiatric Referrals and Adequacy of Psychiatric Resources Several CCEP physicians have noted that there is a high degree of prevalence of psychosocial problems in the CCEP population and that there is a need for standardized guidelines for screening, assessing, evaluating, and treating patients. As discussed in more detail below, 37% of the first 10,020