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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
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 soldiersis 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
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
EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN 27 GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM 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
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.