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OCR for page 7
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
OCR for page 8
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
Representative terms from entire chapter:
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