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Before the Committee on Veterans' Affairs, House of Representatives: 

United States Government Accountability Office: 

For Release on Delivery: 
Expected at 10:00 a.m. EDT:
Wednesday, May 5, 2010: 

VA Health Care: 

Progress and Challenges in Conducting the National Vietnam Veterans 
Longitudinal Study: 

Statement of Randall B. Williamson:
Director, Health Care: 


[End of section] 

Mr. Chairman and Members of the Committee: 

I am pleased to be here today as you discuss the National Vietnam 
Veterans Longitudinal Study (NVVLS). According to the Department of 
Veterans Affairs (VA), experts estimate that up to 30 percent of 
Vietnam veterans have experienced post-traumatic stress disorder 
(PTSD), an anxiety disorder that can occur after a person is exposed 
to a life-threatening event.[Footnote 1] Veterans suffering from PTSD 
may experience problems sleeping, maintaining relationships, and 
returning to their previous civilian lives.[Footnote 2] Additionally, 
studies have shown that many veterans suffering from PTSD are more 
likely to be diagnosed with cardiovascular disease and other diseases. 

After the Vietnam War, Congress wanted information about the 
psychological effects of the war on Vietnam veterans to inform the 
need for PTSD services at VA. Consequently, in 1983, Congress mandated 
that VA provide for the conduct of a study on PTSD and related postwar 
psychological problems among Vietnam veterans.[Footnote 3] VA 
contracted with an external entity, the Research Triangle Institute, 
to conduct the National Vietnam Veterans Readjustment Study (NVVRS). 
[Footnote 4] According to VA, the NVVRS was a landmark study and is 
the only nationally representative study of PTSD in Vietnam veterans. 
PTSD is an ongoing concern for Vietnam veterans, and today, Vietnam-
era veterans still constitute the largest group of veterans receiving 
VA care for PTSD.[Footnote 5] Congress and others have been concerned 
about the continued prevalence of PTSD and VA's capacity to meet the 
needs of Vietnam veterans. In section 212 of the Veterans Benefits and 
Health Care Improvement Act of 2000, Congress required that VA 
contract with an appropriate entity to conduct a follow-up study to 
the NVVRS.[Footnote 6] The law specifies certain requirements that the 
follow-up study must meet, including that the study must use the 
database and sample of the NVVRS and be designed to yield information 
on the long-term effects of PTSD and whether particular subgroups were 
at greater risk of chronic or more severe problems with PTSD. In 2001, 
VA awarded another contract to the Research Triangle Institute to plan 
and conduct a follow-up study, the NVVLS.[Footnote 7] However, in 
2003, before data collection for the study began, VA terminated the 
contract and the study was not completed.[Footnote 8] In September 
2009, the Secretary of Veterans Affairs announced that the agency 
planned to award a new contract to an external entity to conduct the 

My testimony is based on our May 2010 report,[Footnote 9] which is 
being released today, and discusses two issues related to VA's current 
efforts to address the law: (1) the recent progress VA has made in 
conducting the NVVLS and (2) the challenges VA faces in its plans to 
conduct the NVVLS. 

To obtain information about VA's progress in conducting the NVVLS and 
its challenges, we interviewed VA officials responsible for managing 
VA's PTSD research, including officials on the project team 
responsible for restarting the NVVLS.[Footnote 10] We also interviewed 
VA officials who are conducting VA's studies of PTSD in male twin 
Vietnam-era veterans and female Vietnam-era veterans. In addition, we 
obtained and reviewed relevant documents regarding VA's PTSD research 
studies, including a draft performance work statement[Footnote 11] and 
progress report for the NVVLS, study protocols for the studies on male 
twin Vietnam-era veterans and female Vietnam-era veterans,[Footnote 
12] and other documents related to the study methodologies. In order 
to understand how the NVVLS will be conducted, we also obtained and 
reviewed information about the NVVRS and the 2001 NVVLS attempt. 

To provide context for the information we obtained from VA, 
particularly about VA's reported challenges in conducting the NVVLS, 
we interviewed 10 researchers who are currently involved in or have 
previously been involved in managing or conducting PTSD research. 
[Footnote 13] The criteria we used to select the researchers we 
interviewed included expertise in PTSD, as indicated, for example, by 
service on national committees focused on veterans and PTSD, and 
knowledge of or involvement with the NVVRS, the 2001 NVVLS attempt, or 
the NVVLS. We chose these researchers to represent a range of 
perspectives on the studies we examined: for example, we interviewed 
both researchers who are currently employed by VA and researchers who 
are not employed by VA. To obtain additional perspectives on study 
design techniques and feasibility issues, we also interviewed three 
Department of Health and Human Services methodologists: two from its 
Agency for Healthcare Research and Quality and one from its Centers 
for Disease Control and Prevention.[Footnote 14] 

We conducted this performance audit from October 2009 through April 
2010 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

In summary, we found that since September 2009, VA has taken a number 
of steps toward conducting the NVVLS. VA convened a project team for 
the NVVLS consisting of VA officials and PTSD experts both within VA 
and outside of VA. According to VA officials, the NVVLS project team 
developed a performance work statement, which outlines VA's 
requirements for the contractor selected to conduct the NVVLS. 
[Footnote 15] VA expects to select a contractor for the NVVLS in the 
summer of 2010 and for the NVVLS to be completed in 2013. VA officials 
stated that they plan for the NVVLS to meet all of the requirements of 
the law where scientifically feasible. In addition, VA is conducting 
studies of PTSD in male twin Vietnam-era veterans[Footnote 16] and 
female Vietnam-era veterans,[Footnote 17] and VA officials maintain 
that these studies will also provide useful information in response to 
the law. 

VA reported that it faces several challenges in restarting the NVVLS. 
However, in several instances, the researchers and methodologists we 
interviewed offered suggestions for how these challenges could be 
addressed. The challenges reported by VA included the following: 

* Locating and gaining consent from NVVLS participants. VA officials 
stated that they did not know how many of the NVVRS participants can 
be located and would agree to participate in the NVVLS, which could 
impact the feasibility of the study. While 6 of the 10 researchers and 
the 3 methodologists we interviewed agreed that it could be 
challenging to locate the original participants, 9 of the researchers 
offered suggestions for overcoming this challenge, such as using the 
data sources and methods from previous successful efforts to reconnect 
with study participants and taking advantage of current technology. 
[Footnote 18] All 10 researchers and 3 methodologists stated that to 
encourage participation, it was important for NVVLS participants to 
receive assurances of confidentiality--that is, assurances regarding 
use of their identifying information, as was done with the NVVRS 
participants.[Footnote 19] According to VA's draft performance work 
statement for the NVVLS, the NVVLS consent form will not contain these 
assurances of confidentiality but it will state that study 
participation will not affect participants' VA benefits or VA health 
care. However, the draft performance work statement also states that 
the agency plans to take possession of study participants' identifying 
data at the conclusion of the NVVLS. While nine of the researchers 
commented that this requirement could impact whether veterans would 
agree to participate in the NVVLS, VA stated that it conducts many 
internal research studies and has no material issues recruiting study 
participants due to mistrust of VA. 

* Mitigating possible bias in a follow-up study. VA officials said 
that there could be bias in the NVVLS because the NVVRS was not 
designed to accommodate a follow-up study. The three methodologists we 
interviewed stated that this challenge was closely related to the 
challenges of locating the original participants and obtaining their 
agreement to participate in the study--that is, bias will be present 
in the NVVLS if representative participation across the subgroups 
included in the NVVRS is not achieved.[Footnote 20] The methodologists 
stated that if bias in the NVVLS is a concern, VA could survey 
additional individuals from the general Vietnam-era population to 
supplement the original NVVRS cohort or develop a new sample of 
participants from the general Vietnam-era population for the NVVLS. 
VA's draft NVVLS performance work statement states that the contractor 
can choose to examine all or some of the NVVRS participants, but does 
not address the question of whether the contractor could propose to 
survey other Vietnam-era veterans. 

* Assessing PTSD in the NVVLS. VA officials were concerned about 
appropriately assessing PTSD in the NVVLS. Because there was no widely 
accepted PTSD screening method at the time the NVVRS was conducted, 
the study's estimates of PTSD prevalence were based on a multimeasure 
approach involving the use of 10 PTSD assessment instruments 
administered to a subset of NVVRS participants by doctoral-level 
mental health professionals. VA officials stated that this complex 
approach has not been used in other PTSD studies and would not be 
desirable to replicate. Nine of the 10 researchers we interviewed 
stated that the multimeasure method used to identify PTSD in the 
original study was not of concern.[Footnote 21] In order to provide 
comparable longitudinal data, 9 of the researchers and 2 of the 
methodologists we interviewed recommended that the NVVLS contractor 
use PTSD assessment instruments similar or identical to those used in 
the NVVRS in addition to more current approaches.[Footnote 22] 
According to the NVVLS draft performance work statement, the PTSD 
instruments used in the NVVRS should be used in the NVVLS, when 
appropriate, to enhance consistency and facilitate long-term analyses. 
The draft performance work statement also recommends that newer 
measures should be included when possible. 

Overall, VA officials do not know whether, given the challenges they 
face, the NVVLS can be completed. VA's NVVLS draft performance work 
statement includes an initial phase during which VA expects the 
contractor to assess the feasibility of the study. All 10 researchers 
we interviewed said that restarting the study soon is important 
because as the study participants continue to age, an increasing 
number will be lost for follow-up because of illness or death. 
[Footnote 23] Nine of the researchers told us that they believe it is 
important for VA to complete the NVVLS because it will potentially 
provide important, nationally representative information on PTSD and 
related issues in Vietnam-era veterans. 

In responding to a draft of the report from which this testimony is 
based, VA explained its position on the ownership of the NVVRS and 
NVVLS study data. VA stated that the NVVRS contract provided that the 
study data was the property of the agency and did not provide that the 
identifying information be kept from VA. The agency also stated that 
the NVVRS consent documents did not restrict VA from possessing the 
identifying information of participants. VA confirmed that the agency 
intends to receive all the NVVLS study data, including participants' 
identifying information, upon completion of the study, and stated that 
the NVVLS consent form will explain to participants that VA does not 
intend to use the data to determine eligibility for VA benefits. 

Mr. Chairman, this concludes my statement. I would be pleased to 
respond to any questions you or other members of the committee may 

Contacts and Acknowledgments: 

For further information about this testimony, please contact Randall 
B. Williamson at (202) 512-7114 or Contact points 
for our Offices of Congressional Relations and Public Affairs may be 
found on the last page of this testimony. Individuals who made key 
contributions to this testimony include Mary Ann Curran, Assistant 
Director; Susannah Bloch; Stella Chiang; Martha R. W. Kelly; Lisa 
Motley; Rebecca Rust; and Suzanne Worth. 

[End of section] 


[1] Unless otherwise noted, Vietnam veterans refers to those who 
served in Vietnam during the Vietnam era, from February 28, 1961, 
through May 7, 1975. See 38 U.S.C. § 101(29). Estimates for Vietnam 
veterans who have experienced PTSD vary. For example, according to the 
Centers for Disease Control and Prevention's 1989 Vietnam Experience 
Study, about 15 percent of Vietnam veterans have experienced PTSD. 
American Psychiatric Association, Diagnostic and Statistical Manual of 
Mental Disorders, Fourth Edition, Text Revision (Washington, D.C., 

[2] Those diagnosed with PTSD may also suffer from other ailments, 
such as depression and substance abuse. 

[3] Veterans' Health Care Amendments of 1983, Pub. L. No. 98-160, § 
102, 97 Stat. 993, 994-95. This law defined Vietnam veterans as those 
who served in Vietnam or elsewhere in the Vietnam theater of 
operations from August 5, 1964, through May 7, 1975, the Vietnam era. 
See 38 U.S.C. § 101(29) (1982). 

[4] Other collaborators, such as Louis Harris and Associates, Inc., 
and The Graduate Center of the City University of New York, were also 
involved in conducting the NVVRS. 

[5] When we use "Vietnam-era veteran" in this testimony, we are using 
the current governing definition: from February 28, 1961, through May 
7, 1975, for veterans who served in Vietnam, and from August 5, 1964, 
through May 7, 1975, for veterans who served in any other location. 
See 38 U.S.C. § 101(29). 

[6] Pub. L. No. 106-419, § 212, 114 Stat. 1822, 1843-44. Throughout 
this testimony, we refer to section 212 as the law. 

[7] A longitudinal study approach involves the repeated examination of 
a set of study participants over time. 

[8] In this testimony, we use "2001 NVVLS attempt" to refer to the 
efforts that began in 2001 to complete the NVVLS. After the contract 
was terminated, VA's Office of Inspector General investigated the 2001 
NVVLS attempt. The resulting 2005 report found that VA did not 
properly plan or administer the study contract. It recommended that VA 
use appropriate contracting processes to complete the mandated follow-
up study. See Department of Veterans Affairs, Office of Inspector 
General, Audit of VA Acquisition Practices for the National Vietnam 
Veterans Longitudinal Study (2005). 

[9] GAO, VA Health Care: Status of VA's Approach in Conducting the 
National Vietnam Veterans Longitudinal Study, [hyperlink,] (Washington, D.C.: May 5, 

[10] The NVVLS project team is composed of 14 individuals, including 7 
VA officials who are handling various aspects of the study, 3 VA 
representatives who are subject matter experts, 2 non-VA 
representatives who are subject matter experts, and 2 facilitators. 

[11] A performance work statement, also known as a statement of work, 
is a description of the work the government expects the contractor to 

[12] A study protocol is a document that describes the formal design 
of a research study. 

[13] We contacted a total of 13 researchers, but 3 researchers 
declined to speak with us. Two of them felt unable to provide specific 
comments on our issues, and the third stated that he did not have time 
to speak with us. 

[14] In addition, we interviewed representatives of two veteran 
service organizations, the Vietnam Veterans of America and Disabled 
American Veterans, in order to obtain their perspectives on the 
concerns and needs of veterans with PTSD. We also contacted 
representatives from the American Legion. 

[15] We reviewed a draft version of this performance work statement. 

[16] This study, officially titled "A Twin Study of the Course and 
Consequences of PTSD in Vietnam Era Veterans," began in 2006 and is 
projected to finish in 2013. The objectives of the study are (1) to 
estimate the longitudinal course and current prevalence of PTSD; (2) 
to identify the relationships between the longitudinal course of PTSD 
and veterans' current mental and physical health conditions, such as 
cardiovascular disease, diabetes, depression, and substance use 
disorders; and (3) to identify the relationships between PTSD and 
veterans' current functional status and disability. VA estimates that 
5,306 men will participate in the study. This study defines the 
Vietnam era as 1965 through 1975. 

[17] This study, officially titled "Long Term Health Outcomes of 
Women's Service During the Vietnam Era," began in 2008 and is 
projected to conclude in 2014. The study will examine the following 
issues in Vietnam-era female veterans: (1) the prevalence of lifetime 
and current psychiatric conditions, including PTSD; (2) physical 
health; and (3) the level of current disability. According to VA, 
approximately 7,000 women will participate in the study. This study 
defines the Vietnam era as July 4, 1965, through March 28, 1973. 

[18] The one researcher who did not offer a suggestion stated that VA 
may not be able to overcome the challenge. 

[19] The NVVRS provided participants with assurances of 
confidentiality via the NVVRS consent form, which stated that their 
identifying information would not be disclosed in any government 

[20] The NVVRS was required by law to provide information on certain 
subgroups, specifically veterans with service-connected disabilities, 
female veterans, and minorities. 

[21] One researcher thought the method used to identify PTSD in the 
NVVRS was of concern because the PTSD assessment instruments used in 
the method lacked validity. However, this researcher acknowledged that 
these instruments may have been the best available at the time. 

[22] One researcher said that this approach would not necessarily be 
recommended because it may burden the participants and reduce 
participation rates. 

[23] The youngest Vietnam-era veterans still living today would be 
approximately in their early 50s. During the 2001 NVVLS attempt, the 
researchers estimated that 8.5 percent of the Vietnam-era veterans who 
originally participated had died. 

[End of section] 

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