United States General Accounting Office

GAO Testimony

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

VA Health Care: Observations on Medical

Care Provided to Persian Gulf Veterans

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.

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.

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VA Health Care: Observations on Medical

Care Provided to Persian Gulf Veterans

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.

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VA Health Care: Observations on Medical

Care Provided to Persian Gulf Veterans

Persian Gulf Veterans’

Expectations Remain

Unfulfilled

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

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

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

Page 3 GAO/T-HEHS-97-158
VA Health Care: Observations on Medical

Care Provided to Persian Gulf Veterans

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.

Evaluation and Treatment

of Persian Gulf Veterans

Do Not Appear to

Consistently Follow

Guidelines

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.

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.

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VA Health Care: Observations on Medical

Care Provided to Persian Gulf Veterans

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

Page 5 GAO/T-HEHS-97-158
VA Health Care: Observations on Medical

Care Provided to Persian Gulf Veterans

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.

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VA Health Care: Observations on Medical

Care Provided to Persian Gulf Veterans

Medical Centers’

Efforts to Improve

Care for Persian Gulf

Veterans

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.

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.

(101602) Page 7 GAO/T-HEHS-97-158
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