VA Health Care:

Better Integration of Services Could Improve Gulf War Veterans' Care

HEHS-98-197: Published: Aug 19, 1998. Publicly Released: Aug 19, 1998.

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Pursuant to a congressional request, GAO provided information on the Department of Veterans Affairs' (VA) provision of health care services to Gulf War veterans, focusing on: (1) the number of veterans VA and the Department of Defense (DOD) report as suffering from Gulf War-related illnesses and the criteria used to identify these illnesses; (2) how VA diagnoses, counsels, treats, and monitors Gulf War veterans for the health problems they report; and (3) Gulf War veterans' satisfaction with the health care they receive from VA.

GAO noted that: (1) while the number of Persian Gulf War veterans who participated in the military operations known as Desert Shield and Desert Storm is well established at almost 700,000, the number who actually suffer, or believe they suffer, from illnesses related to their Gulf War service remains uncertain 7 years after the war; (2) the primary difficulty in assessing the impact of such illnesses lies in the fact that the link between the veterans' symptoms and the causes of those symptoms has not yet been identified scientifically; (3) thus, while some data on Gulf War veterans' symptoms have been collected and categorized, it is not yet known whether the symptoms reported are the direct result of the veterans' Gulf War service; (4) combined, VA and DOD report, however, that about 100,000 Gulf War veterans have requested Persian Gulf Registry examinations because of war-related health concerns; (5) in response to a variety of symptoms and illnesses reported by Gulf War veterans, VA implemented a program in 1992 to help them receive VA health care; (6) this free diagnostic and referral process has two stages: (a) an initial medical history and a physical examination with basic laboratory testing; and (b) if needed, further evaluation through specialist consultation and additional symptom-specific testing; (7) 212 VA facilities offer the Registry program to Gulf War veterans; (8) however, VA's guidance regarding the evaluation and diagnosis of Gulf War veterans is not being consistently implemented in some of its medical facilities; (9) while VA records show that thousands of veterans remain undiagnosed, only about 500 veterans have been sent to referral centers for additional evaluations, as recommended by the Registry guidance; (10) mandated personal counseling of veterans often does not occur, and the form letters sent to veterans at the completion of the Registry examination do not always sufficiently explain test results or diagnoses, often leaving veterans frustrated and confused; (11) VA's guidance provides that Registry physicians are responsible for giving veterans medical examinations and necessary treatment; (12) VA has not fully developed and implemented an integrated diagnostic and treatment program to meet the health care needs of Gulf War veterans; (13) VA's diagnostic and treatment implementation problems are reflected by Gulf War veterans' general dissatisfaction with their health care; and (14) based on GAO's nationwide survey, over one half of the veterans who received the Registry examination in 1996 and 1997 were dissatisfied with the examination they received.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to uniformly implement a health care process for Gulf War veterans that provides for the coordination of diagnoses of illnesses.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: The DOD/VA Post-Deployment Health Evaluation and Management Clinical Practice Guideline was completed in September 2001. The guideline is meant to assist clinicians in primary care settings in determining specific diagnoses for individuals seeking care for potentially deployment related experiences or exposures. A main guideline objective is to improve local management of patients with post-deployment health concerns and thereby improve patient outcome. The Post-Deployment Health Evaluation and Management Clinical Practice Guideline is available through VA's Office of Quality and Performance (Publication No. 10Q-CPG/PDH-01) or VA's internet web site, http://www.oqp.med.va.gov/cpg/PDH/G/PDH_about.htm.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to uniformly implement a health care process for Gulf War veterans that provides for the coordination of treatment of symptoms and illnesses.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: In March 2002, VA completed work on a significantly updated and revised CME program. The course "A Guide to Gulf War Veterans' Health" represents a complete revision of the independent study released in March 1998. This revised Gulf War independent study module was created as a part of the Veterans Health Initiative (VHI). The VHI is a comprehensive program of continuing education that recognizes the connection between certain health effects and military service, and emphasizes better military medical histories for veteran patients in order to provide them with the best available care. The revised independent study provides an overview of the Gulf War experience, the VA and DoD health programs available for Gulf War veterans, and the common symptoms and diagnoses of these veterans. VHA believes that Gulf War (GW) veterans can receive appropriate care in a variety of settings if the health care providers are adequately informed about their special health concerns. VHA Directive 98-018 defines the requirement that VA physicians complete the independent study, which synthesizes much information on the Gulf War and VA's programs for GW veterans as well as peer-reviewed scientific articles. A mechanism was established to track and test health care providers who completed the self-study material for CME credits.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to uniformly implement a health care process for Gulf War veterans that provides for the coordination of evaluation of treatment effectiveness.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: The Demonstration Projects for Treatment of Gulf War Veterans' Illnesses are now completed. The final reports, as well as summaries, are available on the internet at http://www.va.gov/health/environ/persgulf.htm. In May 2001, two War-Related Illnesses and Injury Study Centers (WRIISC) were established to find effective prevention and treatment for veterans with difficult to diagnose yet debilitating health problems. The WRIISCs are located at the VA medical centers in Washington, D.C., and East Orange, New Jersey. The WRIISCs are responding to the health problems of veterans by improving the care of active duty and veteran patients with war-related illnesses. Additionally, VA and DoD have developed a collaborative Clinical Practice Guideline "Medically Unexplained Symptoms: Chronic Pain and Fatigue." The guideline was developed to assist VA and DoD clinicians responsible for the assessment and care of patients with medically unexplained symptoms of chronic pain and fatigue. The guideline was presented during a live, interactive satellite broadcast on June 27, 2002. The satellite program discussed historical context, key elements, evidence-based assessment and treatment, risk management strategies, and support tools. Final guideline approval is expected in September 2002. A preview draft version is available on the U.S. Army MEDCOM internet site http://www.cs.amedd.army.mil/qmo/mus/guideline.doc.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to uniformly implement a health care process for Gulf War veterans that provides for the coordination of periodic reevaluation of those veterans whose illnesses remain undiagnosed.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: We recommended that the Secretary of Veterans Affairs implement a health care process for Gulf War veterans that provides for the coordination of periodic reevaluation of those veterans whose illnesses remain undiagnosed. VA and DoD have developed a collaborative Clinical Practice Guideline Medically Unexplained Symptoms: Chronic Pain and Fatigue. The guideline was developed to assist VA and DoD clinicians responsible for the assessment and care of patients with medically unexplained symptoms of chronic pain and fatigue. The guideline was presented during a live, interactive satellite broadcast on 6/27/02. The satellite program discussed historical context, key elements, evidence-based assessment and treatment, risk management strategies, and support tools. Final guideline approval is expected in September 2002. A preview draft version is available on the U.S. Army MEDCOM internet site http://www.cs.amedd.army.mil/qmo/mus/guideline.doc.

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