Improving the Presumptive Disability Decision-Making Process for Veterans (2008) / Chapter Skim
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1996. Stroke in former prisoners of war.
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1992. The health of former prisoners of war.
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1991. Prevalence and correlates of depressive symptoms among former prisoners of war.
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1996. Diseases associated with exposure to certain herbicide agents (prostate cancer and acute and subacute peripheral neuropathy)
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787, 1166 SR 91-785 Former Prisoners of (1970)
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787 1166 SR 91-785 (1970) Former Prisoner of War PL 97-37 PL 97-37 HR 97-28 SR 97-88 Benefits Act of 1981 95 STAT.
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Claims Based on 59 FR 42497 38 CFR Part 3 Chronic Effects of Ex posure to Mustard Gas or Lewisite (1994) (final rule)
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and 4 HR 101- SR 101-82 (proposed regulations) 857 SR 101-379 Prepublication Copy – Uncorrected Proof
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(final rule) Disease Associated 59 FR 5161 38 CFR Part 3 with Exposure to Cer tain Herbicide Agents (Multiple Myeloma and Respiratory Cancers)
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(notice) Diseases Associated 61 FR 57586 CFR Part 3 with Exposure to Cer tain Herbicide Agents (Prostate Cancer and Acute and Subacute Peripheral Neuropathy)
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(final rule) Disease Associated 59 FR 29723 38 CFR Part 3 with Exposure to Cer tain Herbicide Agents (Multiple Myeloma and Respiratory Cancers)
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(final rule) Spina Bifida Disease Not Associated 59 FR 341 with Exposure to Cer tain Herbicide Agents (1994)
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1992. The health of former prisoners of war.
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2002. Veterans and Agent Orange: Herbicide/dioxin exposure and acute myelogenous leukemia in the children of Vietnam veterans.
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2001. Costing of regulation RIN 2900-AK83: Presumption of service connection for cirrhosis of the liver in former prisoners of war.
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This background provides a foundation for the Committee's specific recommendations in Chapter 12 which outlines a classification system for characterizing the strength of evidence in support of a general causal relationship. Assuming that such a causal relationship has been established, Chapter 9 discusses how to quantify the strength of the causal effect, using measures most relevant to compensation decisions under the presumptive process: the attributable fraction for the population of exposed veterans, and the probability of causation for an indi Prepublication Copy – Uncorrected Proof 6-1
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Military personnel Prepublication Copy – Uncorrected Proof
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However, this level of information and scientific understanding has not yet been fully achieved for individual causation for any agent. Prepublication Copy – Uncorrected Proof
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For example, the rate of posttraumatic stress disorder (PTSD) in former prisoners of war (POWs)
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Similarly, it is possible to estimate the amount of disease among veterans with a given exposure and given risk profile that exceeds what is observed in otherwise Prepublication Copy – Uncorrected Proof
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, that 50 of the 100 cases among the exposed veterans would have occurred, even if those veterans had not been exposed. Hence, only the remaining 50 or 50/100 = 50 percent are attributable to the exposure as Prepublication Copy – Uncorrected Proof
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Making Presumptions To this point, we have described the concept of service-attributable disease for a population and for an individual. We have indicated that application of a presumption can be thought of Prepublication Copy – Uncorrected Proof
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Exposures in a war theater may vary greatly over space and time and without detailed information Prepublication Copy – Uncorrected Proof
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Paper presented at the 1st meeting of the IOM's Committee on the Evaluation of the Presump tive Disability Decision-Making Process for Veterans, Washington, DC. Prepublication Copy – Uncorrected Proof
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Paper presented at the 3rd meeting of the IOM's Committee on the Evaluation of the Presumptive Disability Decision-Making Process for Veterans, San Antonio, TX. Prepublication Copy – Uncorrected Proof
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We offer an extended discussion of what we mean by cau Prepublication Copy – Uncorrected Proof 7-1
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This potential for bias has prompted the use of the "double-blind" design, in which neither the study personnel in contact with participants nor the participants themselves know the treatment status. A refinement of this design is the crossover study, in which Prepublication Copy – Uncorrected Proof
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One general difficulty of observational studies, regardless of design, is that exposure is not randomized. Rather, exposure status may be determined by where people live or work, what they eat, what social group they belong to, or by a host of other factors that can be associated with Prepublication Copy – Uncorrected Proof
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Their interpretation of the finding as causal was guarded because of some limitations in the several positive studies (e.g., small numbers of deaths) and lack of finding of Prepublication Copy – Uncorrected Proof
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Although tar-stains and smoking are both associated with lung cancer, we can answer these questions because we know the causal mechanisms: smoking is a common cause of tar stains and lung cancer, but tar stains by themselves have no effect on lung cancer mortality. Service connection claims require the same attention to counterfactual questions: what would have been the rate of adult-onset diabetes had Vietnam veterans not been exposed to Agent Orange, for example.
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Note that these Prepublication Copy – Uncorrected Proof
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Age β2 φ Respiratory Exposure β1 Function FIGURE 7-4 Age as a confounder. Prepublication Copy – Uncorrected Proof
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Under this condition, we can separate variation in the cause that might spuriously come from the confounders or from reverse causation from true variation in the cause that will translate to variation in the effect. By using the instru Prepublication Copy – Uncorrected Proof
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For example, consider the diagram in Figure 7-8 below. Prepublication Copy – Uncorrected Proof
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. The other important situation is an additive model of the form Prepublication Copy – Uncorrected Proof
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In sensitivity analysis we attempt to quantify the sensitiv Prepublication Copy – Uncorrected Proof
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SUMMARY Presumptive service-connection decisions depend on population-level causal questions, such as "Were some cases of type 2 diabetes among Vietnam veterans caused by exposure to dioxin in Agent Orange during military service? " Assessing such claims scientifically involves review of statistical evidence from epidemiologic studies, evidence from experiments in other animals, and mechanistic evidence from basic biologic science.
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