VA Health Care: Observations on Medical Care Provided to Persian Gulf
Veterans (Testimony, 06/19/97, GAO/T-HEHS-97-158).

GAO discussed its ongoing evaluation of the medical care the Department
of Veterans Affairs (VA) provides to veterans who are suffering from
illnesses they attribute to their military service during the Persian
Gulf war, focusing on: (1) veterans' satisfaction with VA care; and (2)
the extent to which veterans are diagnosed, counseled, treated, and
monitored.

GAO noted that: (1) the Persian Gulf veterans that GAO has talked with
and who wrote to GAO, along with the veterans' service organizations GAO
talked with, appeared to be confused by, frustrated with, and
mistrustful of VA and the care they received for their illnesses; (2)
while veterans appreciated the efforts of individual VA staff, they
expressed dismay with the "system," which often extends beyond VA to
other agencies and, for some, to the federal government in general; (3)
specifically, veterans continued to cite delays in receiving services,
the nonsympathetic attitudes of some health care providers, the
sometimes cursory nature of the registry exam, poor feedback and
communication with health care personnel, and a lack of postexamination
treatment; (4) on the basis of GAO's work to date, it does not appear
that VA's guidance regarding the evaluation and treatment of Persian
Gulf veterans is being consistently implemented in the field; (5) GAO
observed, for example, that some physicians did not perform all of the
symptom-specific tests recommended by VA's Uniform Case Assessment
Protocol, which could result in some veterans not receiving a clearly
defined diagnosis for their symptoms; (6) GAO also found the personal
counseling of veterans seldom occurred; (7) in addition, the form
letters sent to veterans at the completion of the registry exam did not
always sufficiently explain the test results or diagnosis, which leaves
veterans frustrated; (8) physicians' views were mixed regarding the
origin of the symptoms experienced by Persian Gulf veterans; (9) GAO
heard and read physician comments indicating that they believe Persian
Gulf veterans' problems are only "in their heads"; (10) however, other
physicians displayed open attitudes about treating the veterans'
symptoms and determining the origin of their illnesses; (11) medical
center personnel cited limited resources and increased workloads as
reasons their efforts are not as timely and responsive as they and
veterans would like; (12) one medical center GAO visited had experienced
delays of up to 6 months in scheduling registry exams; (13) however,
steps are being taken at certain VA facilities to improve service; (14)
for example, at one medical center GAO visited, veterans now have the
option of receiving treatment in a Persian Gulf Special Program Clinic;
and (15) the Clinic allows veterans to receive primary care from medica*

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-97-158
     TITLE:  VA Health Care: Observations on Medical Care Provided to 
             Persian Gulf Veterans
      DATE:  06/19/97
   SUBJECT:  Health care services
             Managed health care
             Medical examinations
             Veterans benefits
             Health centers
             Physicians
             Health services administration
             Disease detection or diagnosis
             Military personnel
IDENTIFIER:  VA Persian Gulf War Health Registry
             Persian Gulf War
             
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Cover
================================================================ COVER


Before the Subcommittee on Health, Committee on Veterans' Affairs,
House of Representatives

For Release on Delivery
Expected at 9:30 a.m.
Thursday, June 19, 1997

VA HEALTH CARE - OBSERVATIONS ON
MEDICAL CARE PROVIDED TO PERSIAN
GULF VETERANS

Statement of Stephen P.  Backhus, Director
Veterans' Affairs and Military Health Care Issues
Health, Education, and Human Services Division

GAO/T-HEHS-97-158

GAO/HEHS-97-158T


(101602)


Abbreviations
=============================================================== ABBREV

  VA - Department of Veterans Affairs
  ABC - Test

VA HEALTH CARE:  OBSERVATIONS ON
MEDICAL CARE PROVIDED TO PERSIAN
GULF VETERANS
============================================================ Chapter 0

Mr.  Chairman and Members of the Subcommittee: 

We are pleased to be here today to discuss our ongoing evaluation of
the medical care the Department of Veterans Affairs (VA) provides to
veterans who are suffering from illnesses they attribute to their
military service during the Persian Gulf War. 

Persian Gulf veterans have reported an array of symptoms including
fatigue, skin rashes, headaches, muscle and joint pain, memory loss,
shortness of breath, sleep disturbances, gastrointestinal conditions,
and chest pain.  VA's program to serve Persian Gulf veterans is a
four-pronged approach addressing medical care, research,
compensation, and outreach and education.  The medical care portion
includes a medical examination,\1 inpatient and outpatient treatment,
specialized evaluations at four referral centers, and readjustment
and sexual trauma counseling.  More than 65,000 Persian Gulf veterans
have completed the medical examination, or "registry exam."

My comments this morning will focus on information we have gathered
to date, at your request, on (1) veterans' satisfaction with VA care
and (2) the extent to which veterans are diagnosed, counseled,
treated, and monitored.  We will also discuss a model of care at one
medical center that Persian Gulf veterans seem to find more
responsive to their needs. 

Our information is based on observations and opinions from officials
at VA headquarters; VA's Atlanta Veterans Integrated Service Network
office; medical centers in Washington, D.C., Atlanta, and Birmingham;
referral centers in Washington and Birmingham; and veterans service
organizations; and from dozens of Persian Gulf veterans, both
individually and in group interviews.  We also reviewed a sample of
medical records for 20 veterans who had received the registry exam in
two of the three medical centers we visited to evaluate the registry
exam process.  We did not attempt to determine whether the tests,
evaluations, and treatment provided to these veterans were
appropriate but rather the extent to which VA followed its guidelines
for evaluation and treatment and whether Persian Gulf veterans were
satisfied with the treatment received.  While the scope of our work
to date is not broad enough to generalize to conditions throughout
VA, we believe that, along with previous studies of these issues, our
work does serve as an indicator of the medical care that Persian Gulf
veterans receive. 

The Persian Gulf veterans that we have talked with and who wrote to
us, along with veterans we heard about through veterans service
organizations, appeared to be confused by, frustrated with, and
mistrustful of VA and the care they received for their illnesses. 
While veterans appreciated the efforts of some individual VA staff,
they expressed dismay with the "system," which often extends beyond
VA to other agencies and, for some, to the federal government in
general.  Specifically, veterans continued to cite delays in
receiving services, the nonsympathetic attitudes of some health care
providers, the sometimes cursory nature of the registry exam, poor
feedback and communication with health care personnel, and a lack of
postexamination treatment. 

On the basis of our work to date, it does not appear that VA's
guidance regarding the evaluation and treatment of Persian Gulf
veterans is being consistently implemented in the field.  We
observed, for example, that some physicians did not perform all of
the symptom-specific tests recommended by VA's Uniform Case
Assessment Protocol, which could result in some veterans not
receiving a clearly defined diagnosis for their symptoms.  We also
found that personal counseling of veterans seldom occurred.  In
addition, the form letters sent to veterans at the completion of the
registry exam did not always sufficiently explain the test results or
diagnosis, which leaves veterans frustrated.  Physicians' views were
mixed regarding the origin of the symptoms experienced by Persian
Gulf veterans.  We heard and read physician comments indicating that
they believe Persian Gulf veterans' problems are only "in their
heads." However, other physicians displayed open attitudes about
treating the veterans' symptoms and determining the origin of their
illnesses. 

Medical center personnel cited limited resources and increased
workloads as reasons their efforts are not as timely and responsive
as they and veterans would like.  One medical center we visited had
experienced delays of up to 6 months in scheduling registry exams. 
However, steps are being taken at certain VA facilities to improve
service.  For example, at one medical center we visited, veterans now
have the option of receiving treatment in a Persian Gulf Special
Program Clinic.  The Clinic allows veterans to receive primary care
from medical staff experienced with Gulf War veterans and their
concerns and has established a focal point for providing clinical
management of Persian Gulf veterans' care. 


--------------------
\1 The Persian Gulf Registry Exam consists of a medical history,
physical examination, and laboratory tests.  The results of the
examination are entered into a database that contains information on
all Persian Gulf veterans who have received the examination. 


   PERSIAN GULF VETERANS'
   EXPECTATIONS REMAIN UNFULFILLED
---------------------------------------------------------- Chapter 0:1

The Persian Gulf veterans we spoke with held several common
expectations regarding VA health care.  They expected to be scheduled
for the registry exam and tested in a timely manner.  They expected
doctors to listen to their symptoms and to take the problems they
experienced seriously by performing the necessary tests and
evaluations in order to reach a diagnosis.  The veterans expected to
be told their test results and to receive counseling and consultation
regarding the need for further testing or treatment. 

Veterans' perceptions of what is provided, however, were considerably
different.  Some veterans said they experienced delays in receiving
the registry exam and follow-up testing they requested.  Once
scheduled for care, veterans said that some VA doctors and health
care professionals projected the attitude that the symptoms Persian
Gulf veterans experience are "all in their heads." Some veterans
commented that the exam they received seemed too superficial to fully
evaluate the complex symptoms they were experiencing. 

Veterans indicated that personal counseling is generally not provided
on the results of the registry exam and that this is true for
veterans with diagnoses as well as for those without.  The form
letter sent to veterans at the completion of the exam generated
considerable anger among Persian Gulf veterans we talked with, who
interpreted it to mean that since their test results came back
normal, the VA physician believed there was nothing wrong with them. 
Even some veterans who received a diagnosis did not understand their
diagnosis or believe that their treatment was effective.  For
example, several veterans believed their medications made them feel
worse and discontinued them on their own. 


   EXTENT OF SERVICES PROVIDED TO
   PERSIAN GULF VETERANS
---------------------------------------------------------- Chapter 0:2

Many Persian Gulf veterans have received care from VA for what they
believe are service-related illnesses.  These illnesses are
manifested in a wide range of symptoms in multiple diagnostic
categories.  Although VA has developed comprehensive guidance for
physicians to use in diagnosing Persian Gulf veterans, it appears to
be inconsistently followed. 


      MEDICAL SERVICES PROVIDED TO
      PERSIAN GULF VETERANS
-------------------------------------------------------- Chapter 0:2.1

The medical care portion of VA's approach is provided in a variety of
settings.  Of the total 697,000 veterans who served in the Persian
Gulf War, more than 65,000 have completed the registry exam, which is
available in most of VA's 159 medical centers.  More than 191,000
veterans have been seen in VA's outpatient care clinics; about 19,000
veterans have been admitted to inpatient care in VA medical centers. 
Approximately 390 veterans have received special evaluations in
referral centers in Washington, D.C., Birmingham, Houston, and Los
Angeles; and more than 79,000 have received readjustment counseling
at VA's Vet Centers.\2

The diagnoses recorded in the registry exam database for Persian Gulf
veterans spanned a range of illnesses and diagnostic categories. 
About 25 percent of registry diagnoses were for musculoskeletal and
connective tissue disorders, approximately 15 percent for respiratory
problems, 12 percent for gastrointestinal conditions, 14 percent for
skin disorders, 16 percent for psychiatric conditions, 7 percent for
cardiovascular and circulatory problems, 7 percent for infectious
diseases, and 5 percent for injury and poisoning.  Twenty-six percent
of registry participants did not have a definitive medical diagnosis,
and 12 percent reported no health problem.\3 The latter group asked
to participate in the examination because they were concerned that
their future health might be affected as a consequence of their
service in the Gulf War. 


--------------------
\2 These numbers represent individual veterans provided service in
each setting.  The same veteran could be counted more than once if he
or she was seen in more than one setting.  Also, for outpatient
visits, VA's data do not indicate whether the veterans were seen for
Persian Gulf-related illnesses. 

\3 Percentages total more than 100 percent because some veterans have
multiple diagnoses. 


      EVALUATION AND TREATMENT OF
      PERSIAN GULF VETERANS DO NOT
      APPEAR TO CONSISTENTLY
      FOLLOW GUIDELINES
-------------------------------------------------------- Chapter 0:2.2

In 1995, VA implemented a Uniform Case Assessment Protocol designed
in conjunction with the Department of Defense and the National
Institutes of Health to provide guidance to the physicians
responsible for administering the Persian Gulf Registry Exam.  The
protocol consists of two phases.  Phase I requires registry
physicians to (1) obtain a detailed medical history, which includes
collecting information on exposure to environmental and biochemical
hazards; (2) conduct a physical examination; and (3) order basic
laboratory tests.  Phase II, which is to be undertaken if veterans
still have symptoms that are undiagnosed after phase I, includes
additional laboratory tests, medical consultations, and
symptom-specific tests.  Veterans who do not receive a diagnosis
after phase II may be sent to one of VA's four referral centers for
additional testing and evaluation.  At the completion of these
examinations, veterans are to receive personal counseling about their
test results.  Once diagnosed, veterans are generally referred to
primary care teams for treatment.  VA has issued a contract to the
Institute of Medicine to review the appropriateness of its Uniform
Case Assessment Protocol.  The Institute's findings are due by the
end of 1997. 

Presently, the protocol remains VA physicians' primary reference on
how to evaluate Persian Gulf veterans' conditions and to obtain an
accurate diagnosis of the symptoms they report.  According to VA's
guidance, the veterans registry physician or designee is responsible
for clinical management of veterans on the registry and serves as
their primary health care provider unless another physician has been
assigned this responsibility.  According to VA program guidance, the
registry physician's essential responsibilities include counseling
the veteran as to the purpose of the examination, conducting and
documenting the physical examination, and personally discussing with
each veteran the examination results and need for additional care. 
The registry physician is also to prepare and sign a follow-up letter
explaining the results of the registry examination and may initiate,
if necessary, the patient's further evaluation at one of VA's
referral centers. 

On the basis of our review of medical records and discussions with
program officials, including physicians, it does not appear that VA's
guidance is being consistently implemented in the field.  For
example, while the protocol mandates that veterans without a clearly
defined diagnosis are to receive additional baseline laboratory tests
and consultations, not all such veterans received the full battery of
diagnostic procedures.  In some cases, physicians appeared to stop
following the protocol even though a clearly defined diagnosis had
not been reached.  In addition, several of the records we reviewed
indicated that the physician's diagnosis was simply a restatement of
the veteran's symptoms.  For example, a veteran who complained of
major joint stiffness and sleep disturbances was diagnosed as having
major joint stiffness and sleep disturbances.  Furthermore, veterans
suffering from undiagnosed illnesses were rarely evaluated at VA's
referral centers; of the approximately 15,000 cases that VA reported
as having undiagnosable illnesses, only 390 veterans had been
evaluated at a referral center.  While VA has a quality assurance
mechanism for evaluating the care provided by its medical centers,
that mechanism neither ensures continuity of care for Persian Gulf
veterans nor provides for follow-up with veterans who need continued
care.  As a result, veterans are often confused about the status of
their ongoing treatment. 

At two locations we visited, the registry physician was rarely
involved in the phase I examination process, instead delegating this
task to a physician's assistant or nurse.  In several cases, medical
records indicated that the registry physician did not even review the
results of the examination.  After the phase I examination, instead
of receiving ongoing treatment managed by the registry physician,
veterans were referred to one of the medical center's primary care
teams for postexamination treatment.  Here, Persian Gulf veterans are
seen by other doctors who treat all veterans and do not concentrate
on the specific needs of Persian Gulf veterans.  Veterans who expect
treatment designed for those suffering from Gulf War illnesses
appeared more likely to express frustration and disappointment with
the care they received. 

According to VA guidance, counseling the veteran about the
examination results is one of the key responsibilities of the
registry physician.  However, our work to date suggests that personal
counseling between veterans and their physicians rarely takes place. 
Registry medical staff, as well as veterans we talked with, stated
that feedback on examination results is typically provided through a
form letter to veterans.  The letter generally states the results of
laboratory tests and provides a diagnosis if one was reached.  In
some instances, when laboratory results were negative, the veteran
perceived that VA does not believe there is a problem.  Even when a
diagnosis is reached, the letter does not explain the meaning of
complex or uncommon medical terms. 

We discussed these concerns with registry and other physicians as
well as VA Persian Gulf program officials.  Several of the physicians
we interviewed believed they should have the flexibility to use their
own clinical judgment in determining which tests are necessary to
establish a diagnosis and treatment plan.  One physician stated that
a good physician should, in most cases, be able to diagnose a
veteran's symptoms without using the more complex battery of tests
mandated by the protocol.  We were told that some of the phase II
symptom-specific tests are invasive procedures that could have
serious side effects, and unless the tests are specifically needed,
they should not be given routinely just because a veteran has
symptoms.  Other physicians resisted prescribing some phase II tests
because of the associated costs.  Furthermore, some physicians told
us that they believed there was no physical basis for the symptoms
Persian Gulf veterans were experiencing and that these symptoms were
often psychologically based and not very serious.  This attitude may
contribute to physicians' lack of enthusiasm for the protocol exams. 

We also noted that VA has established no mechanism to monitor
treatment outcomes for Persian Gulf veterans.  The VA official
responsible for the Persian Gulf program told us that if monitoring
of treatment outcomes does occur, it will be initiated in primary
care. 


   MEDICAL CENTERS' EFFORTS TO
   IMPROVE CARE FOR PERSIAN GULF
   VETERANS
---------------------------------------------------------- Chapter 0:3

Medical center personnel often cited limited resources and increased
workloads as reasons their efforts were not as timely and responsive
as they and veterans would like.  Some facilities are taking steps to
overcome the negative experiences of Persian Gulf veterans.  For
example, one of the three medical centers we visited uses a different
model to provide care to these veterans.  At this facility, veterans
have the option of receiving treatment in a Persian Gulf Special
Program Clinic.  Although it operates only on Tuesdays and Fridays,
the Clinic allows veterans to receive primary care from medical staff
experienced with Gulf War veterans and their concerns.  Veterans are
still referred to hospital specialists as necessary but, unlike the
other two facilities we visited, responsibility for monitoring
patients' overall medical treatment is assigned to the Clinic's case
manager.  The case manager is a registered nurse who serves as an
advocate for veterans and facilitates communications between
patients, their families, and the medical staff.  The specific steps
that are to be used in monitoring patient care had not been developed
at the time of our visit.  The Clinic staff also interacts regularly
with the Persian Gulf Advisory Board, a local group of Persian Gulf
veterans who meet weekly in the VA medical center to discuss specific
concerns. 

Veterans we spoke with were pleased with the Clinic and supported its
continued operation.  They believed that it reflects a VA commitment
to take seriously the health complaints of Gulf War veterans.  They
also believed that the Clinic gives veterans access to physicians who
are sympathetic and understand the special needs of Persian Gulf
veterans and their families.  In addition, veterans we talked with
who use this facility indicated a higher level of satisfaction with
the care they received than the veterans who use the two other
medical centers. 


-------------------------------------------------------- Chapter 0:3.1

Mr.  Chairman, this concludes my prepared statement.  We will
continue to assess these issues and will report our findings and
conclusions at a later date.  I will be happy to answer any questions
you or other members of the Subcommittee may have. 


*** End of document. ***