Gulf War Illness: Improvements Needed for VA to Better Understand, Process, and Communicate Decisions on Claims
Published: 2017-06-29T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: VA estimates that 44 percent of veterans who served in the Persian Gulf War in 1990-91 have medical issues commonly referred to as Gulf War Illness and that those who have been deployed to Southwest Asia since then may suffer from similar medical issues. These medical issues may entitle a veteran to VA benefits. Recently, questions have been raised about whether VA is processing GWI claims correctly. GAO was asked to review VA's handling of these claims.
This report examines (1) recent trends in GWI disability claims, (2) challenges associated with accurately processing and clearly communicating decisions on GWI claims, and (3) how VA uses GWI research to inform the disability compensation program. GAO reviewed relevant federal laws, regulations, and guidance; analyzed VA data on GWI-related claim decisions from fiscal years 2010–2015 (the most recent data available); visited 4 of 58 regional offices, choosing those with high GWI caseloads; and interviewed headquarters and regional VA staff and key stakeholders. GAO also reviewed a non-generalizable sample of 44 claim files to provide illustrative examples of how VA evaluated and communicated decisions on GWI claims.
section_title: What GAO Found
paragraphs: The Department of Veterans Affairs (VA) completed processing about 11,400 Gulf War Illness (GWI) claims in fiscal year 2015, which was more than double the 4,800 claims processed in fiscal year 2010. GWI is a collective term for certain medical conditions among veterans who have served in Southwest Asia since 1990. Symptoms of GWI can include joint pain, gastrointestinal problems, fatigue, and neurological problems. On average, GWI claims have twice as many medical issues per claim as other disability claims, and take 4 months longer to complete. During fiscal years 2010 through 2015, the most recent data available at the time of our review, approval rates for GWI claims were about three times lower than for all other claimed disabilities. Several factors may contribute to lower approval rates, including that—according to VA—GWI claims are not always well understood by VA staff and veterans sometimes file for benefits without medical records to adequately support their claim.
VA's ability to accurately process GWI claims is hampered by inadequate training, and its decision letters for denied claims do not communicate key information to veterans. VA claims rating staff often rely on VA medical examiners to assess a veteran's disability before a decision can be made on a claim. VA medical examiners told GAO that conducting Gulf War general medical exams is challenging because of the range of symptoms that could qualify as GWI. VA has developed elective GWI training for its medical examiners, but only 10 percent of examiners had taken the training as of February 2017. Federal internal control standards call for adequate training for staff so they can correctly carry out an agency's procedures. Medical examiners who do not take this GWI-specific training may not be able to provide information to VA staff to correctly decide whether to grant a veteran's claim. Once a determination is made, VA regulations also require clear explanations to veterans regarding claim decisions. GAO found that decision letters for GWI claims do not always include key information on why the claim was denied.
VA considers research when adding to the list of conditions it associates with Gulf War service, but it does not have a plan to develop a uniformly used case definition of GWI. In 2010, VA added nine infectious diseases to the list of GWI-related conditions. VA advisory groups noted, however, that researchers face obstacles in conducting GWI research, including the lack of a single case definition of the illness for research and treatment purposes. In its 2015 Gulf War Research Strategic Plan, VA included an objective to develop a single case definition, but an official told GAO that VA had no action plan in place to achieve it. Without a plan to achieve a single case definition, research on and treatment for GWI may continue to progress slowly.
section_title: What GAO Recommends
paragraphs: GAO recommends that VA require GWI training for medical examiners, improve its decision letters, and develop a plan to establish a single GWI case definition. VA agreed with GAO's recommendations.

section_title: Letter
paragraphs: The Persian Gulf War in 1990-1991—known as Operations Desert Storm  and Desert Shield—was the beginning of the U.S. military’s involvement  in a series of Gulf War conflicts that continue to this day. The Department  of Veterans Affairs (VA) estimates that 44 percent of the nearly 700,000  service members who served in 1990–1991 in the Persian Gulf War now  have what is commonly referred to as Gulf War Illness—a cluster of  chronic symptoms that can include fatigue, headaches, joint pain,  indigestion, insomnia, respiratory disorders, skin problems, and memory  impairment. The exact causes of the illness are not always known and  symptoms among these veterans vary widely.
VA provides disability compensation benefits to veterans with disabling  conditions that were incurred during or aggravated by their military  service. VA’s Veterans Benefits Administration (VBA) determines  veterans’ eligibility and payment amounts based on medical records and  examinations, military service records, and other evidence. As part of  reviewing evidence to decide the claim, VBA staff may request a medical  examination if they deem it necessary. To support the disability claim  process, medical examiners at VA’s Veterans Health Administration  (VHA) conduct medical exams of veterans at VA health care facilities.
For Gulf War Illness-related disability compensation, however, VA can  award benefits to certain veterans who have served in a Gulf War conflict  from 1990 and display certain Gulf War Illness symptoms without the  veteran having to prove the symptoms are related to their military service.  Even so, VBA may request a medical examination from VHA to assess  the severity of the veteran’s disability. According to VBA officials, VA does  not publicly report on the total number of Gulf War veterans who receive  disability compensation benefits for Gulf War Illness. For years, members  of Congress have questioned VA’s treatment of Gulf War Illness, and  veterans’ advocacy organizations have noted that the claims are not well  understood by VA staff, are difficult for the veteran to substantiate, and  are denied at higher rates than other claims. You requested information  on VA’s processing of Gulf War Illness disability claims. This report  examines (1) trends in Gulf War Illness disability claims in recent years,  (2) challenges associated with accurately processing and clearly  communicating decisions on Gulf War Illness disability claims, and (3)  how VA uses Gulf War Illness research in its disability compensation  program.
To identify trends in Gulf War Illness disability claims, we analyzed VBA  administrative data from fiscal year 2010 through 2015 (the most recent  data available at the time of our review) on the number of completed Gulf  War Illness claims and their approval rates. We assessed the reliability of  VA’s administrative data used in our analysis by performing electronic  testing, reviewing documentation about the data and the system that  produced them, and interviewing agency officials knowledgeable about  the data. We determined these data were sufficiently reliable for the  purposes of our reporting objectives and have noted in our report any  limitations that are associated with the data we present on trends in Gulf  War Illness claims decisions.
To identify challenges associated with accurate processing of Gulf War  Illness claims and clearly communicating decisions on those claims, we  compared VA’s processes against the agency’s internal guidance and  federal internal control standards. We also interviewed VBA and VHA  officials responsible for developing and implementing guidance, training,  and quality assurance related to Gulf War Illness claims. We visited 4 of  VBA’s 58 regional offices and nearby VHA health care facilities at each  location to gain perspectives of the staff who process and evaluate Gulf  War Illness claims. We also reviewed a non-generalizable sample of 44  claim files that were completed in fiscal year 2015 from the 4 regional  offices we visited to provide illustrative examples of how VBA processes  and communicates decisions about Gulf War Illness claims. Specifically,  we compared Gulf War Illness decision letters to VA’s guidance on  preparing these letters.
To examine how VA uses Gulf War Illness research in its disability  compensation program, we reviewed relevant federal laws and  regulations and VA’s Gulf War Research Strategic Plan, and we  interviewed VA officials responsible for VA’s Gulf War research program,  as well as VA clinicians and medical researchers. We also reviewed  recent Gulf War Illness-related reports and recommendations made to VA  from internal task forces, external advisory groups, and the National  Academy of Medicine (formerly the Institute of Medicine), and we  compared VA’s actions to federal internal control standards. For  additional details on our scope and methodology, see appendix I.
We conducted this performance audit from October 2015 to June 2017 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.
subsections: section_title: Background
subsections: section_title: What Is Known about Gulf War Illness
paragraphs: Since the Persian Gulf War began 27 years ago, the U.S. military has  maintained a continuing presence in Southwest Asia (see fig. 1).
According to VA, more than 1.1 million U.S. service members have been  deployed to the region since the start of the Persian Gulf War. Since  returning, many of these veterans have experienced medical issues  unique to their service in the Southwest Asia theater of operations.  According to VA, service members and veterans began reporting  symptoms after their return from service in the Persian Gulf War in 1991.  The exact cause of the symptoms was unknown, but according to the  Department of Defense, U.S. troops might have been exposed to a  variety of potentially hazardous substances, such as pesticides, smoke  from oil well fires, and depleted uranium that could be linked to their  medical conditions. The symptoms Gulf War veterans were describing did  not correspond easily to recognized categories of diseases, and  presented a problem for health care diagnoses and treatment procedures,  as well as for VBA staff who evaluate disability compensation claims.  Because the problem involved a significant percentage of Gulf War  veterans—at the time, estimated at 25 percent—VA initiated research  seeking to explain these chronic illness patterns.
VA can provide disability compensation benefits to Gulf War veterans  under different circumstances than for other veterans. Federal law  generally entitles veterans with diseases or injuries incurred or  aggravated in active military service to disability compensation benefits if  the veteran can prove they were related to their service (i.e., service  connected disability). For any veteran with certain illnesses who served  in Southwest Asia from 1990 to the present, however, VA can provide  disability compensation without the veteran needing to prove their  illnesses were caused or aggravated by service. Rather, VA “presumes”  these illnesses were due to their service in the Southwest Asia theater of  operations (i.e., a presumptive service connection). Specifically, VA  provides disability compensation benefits to veterans who served in  Southwest Asia for illnesses that fall into the following three categories:  (1)  Undiagnosed illnesses (established in 1994);  (2)  Medically unexplained chronic multisymptom illnesses  (established in 2001); and  (3)  Nine specific infectious diseases (established in 2010).
Each of these categories includes many symptoms or illnesses that could  qualify a veteran for benefits (see fig. 2). Because symptoms vary widely,  VA prefers not to use the term “Gulf War Illness,” though it is often  referred to as such by VA clinicians and in medical literature. We will  collectively refer to disability claims for these three categories of illnesses  as Gulf War Illness claims.
section_title: VA’s Disability Compensation Process for Gulf War Illness Claims
paragraphs: All three categories of Gulf War illnesses (undiagnosed illness, medically  unexplained chronic multisymptom illness, and infectious diseases) are  presumed to be related to a veteran’s service in the Gulf War. For  infectious disease claims, however, the process for evaluating the claim  can be different than for undiagnosed illnesses and medically  unexplained chronic multisymptom illnesses. Claims related to infectious  diseases are generally more straightforward for VBA to process because  they are diagnosable conditions related to known exposures in Southwest  Asia. If a veteran is diagnosed with one of the qualifying infectious  diseases and meets the other criteria in the law, their claim will be  granted on a presumptive basis.
Claims for undiagnosed illness and medically unexplained chronic  multisymptom illness can be more complicated for VBA to process, in  part, because of the largely unknown nature of the exposures that cause  the symptoms and the wide variation in symptoms among veterans. To  qualify for disability compensation under a presumptive service  connection based on symptoms of undiagnosed illness or medically  unexplained chronic multisymptom illness, veterans must meet certain  criteria (in addition to certain criteria all veterans must meet to qualify for  disability compensation):  (1)  They must have served on active military duty in the Southwest  Asia theater of operations at any time from August 2, 1990, to the  present.  (2)  They must have a chronic disability resulting from an undiagnosed  illness, a medically unexplained chronic multisymptom illness, or a  combination of both, that manifested either during active duty or to  a degree of 10 percent or more not later than December 31,  2021.
For these two categories of Gulf War Illness claims, VBA Rating  Veteran’s Service Representatives—claims raters—often rely on  information from VHA medical examiners to support their decision on  whether to grant or deny a claim. If claim raters determine a medical exam is warranted, it can play an important role in determining whether a  claim is Gulf War Illness-related. See figure 3 for an overview of the  process for evaluating claims for undiagnosed illnesses and medically  unexplained chronic multisymptom illnesses.
The medical examiner conducts an exam of the veteran and reviews the  veteran’s medical records to determine whether the veteran has a chronic  disability pattern. If there is no record of prior treatment in the medical  records and no other evidence in the claim file documenting symptoms  associated with undiagnosed illnesses or chronic multisymptom illnesses,  then there is no evidence of a chronic disability and no basis for granting  the claim. However, if a medical examiner finds evidence of a chronic  disability or illness, they must indicate in the exam report whether the  veteran has:  (1)  an undiagnosed illness,  (2)  a diagnosable but medically unexplained multisymptom illness of  (3)  a diagnosable multisymptom illness with a partially understood  cause (which is not rated on a presumptive basis as a Gulf War  Illness), or  (4)  a disease with a clear and specific cause and diagnosis (which is  not rated on a presumptive basis as a Gulf War Illness).
Depending on which of these categories the medical examiner  determines the veteran’s disability falls into, it may be necessary for the  examiner to include in the exam report a medical opinion as to whether  the condition may have been caused by their service. If the medical  examiner determines the veteran’s disability pattern is either category (1)  or (2)—presumptive conditions—then no medical opinion on potential  service connection from the examiner is necessary as these conditions  are presumed to be caused by service in the Southwest Asia theater of  operations. If the medical examiner determines that the veteran’s  disability pattern is either category (3) or (4), then they are not considered  presumptive conditions, and the medical examiner is instructed to include  their medical opinion with supporting rationale as to whether the veteran’s  disability pattern is “at least as likely as not” related to the veteran’s  service.
The VBA claims rater will review all of the evidence, including any Gulf  War general medical examination report completed by VHA and other  evidence in the veteran’s claim file, to determine eligibility for  compensation. If the medical examiner’s report indicates the veteran’s  illness or symptoms should be in category (1) or (2), the claims rater can  presumptively award benefits for Gulf War Illness (as long as all other  requirements are met). However, if the medical examiner’s report  indicates the veteran’s illness or symptoms should be placed into  category (3) or (4), the claims rater will evaluate the claim under the direct  service connection method. For the purposes of this report, claims that  fall into categories (3) and (4) would not be considered Gulf War  Illnesses.
For all disability claims, VBA claim processing staff are required to explain  the reason for each claim decision in a decision letter. VBA sends the  decision letter to the veteran notifying the veteran of the decision, as well  as a notice of the veteran’s rights should they disagree with VBA’s  decision. According to VA regulations, decision letters should clearly state  (1) the decision made; (2) any applicable effective date; (3) the reason(s)  for the decision; (4) a claimant’s right to a hearing on any issue involved  in the claim; and (5) a claimant’s right of representation and the right to  appeal the decision, including procedures and time limits.
section_title: Prior VA Efforts to Improve Services for Gulf War Veterans
paragraphs: In 2009, the Secretary of VA established an internal Gulf War Veterans’  Illnesses Task Force with participation from across the agency to conduct  a comprehensive review of all VA programs and services that serve the  cohort of 1990-1991 Persian Gulf War veterans. The Task Force was  charged with identifying gaps and opportunities to improve programs and  services, as well as providing recommendations to address the needs of  this veterans’ cohort. This Task Force released its first report, including  recommendations, in September 2010 and its last report in January 2014.  Following the release of the 2014 Task Force report, VA’s Chief of Staff  established a different internal workgroup to review, validate, and  recommend a strategy to address Gulf War veterans’ needs and  concerns. According to a June 2014 report published by this internal  workgroup, VA had yet to implement many recommendations related to  programs and services for Gulf War veterans made by internal task forces  and external advisory committees to senior VA leadership over the years.  In June 2014, this workgroup’s environmental scan identified several  deficiencies regarding VA’s response to Gulf War Illness, including that  there is: no overarching Department-level strategy for Gulf War veterans; no well-coordinated process for receiving recommendations or  implementing plans to respond to recommendations; and no clear consensus on a single case definition for Gulf War Illness.
The workgroup recommended that VA take a more coordinated and  integrated approach to addressing persistent gaps in VA’s strategy to  care for Gulf War veterans, and identified steps for VA to take to ensure  the agency follows up on its stated plans.
section_title: VA’s Gulf War Illness Research Program
paragraphs: From fiscal years 1994 through 2015, VA has funded more than $160  million dollars of Gulf War Illness-related medical research, with $12.3  million in funding for fiscal year 2016. VA has two offices—both located  within the VHA—that conduct Gulf War Illness research: the Offices of  Research and Development, and Post-Deployment Health. The Office of  Research and Development administers VA’s Gulf War Illness research  program, including setting the strategic direction, developing requests for  applications, evaluating and awarding funds, and overseeing ongoing  research grants. Post-Deployment Health conducts research on the  potential causes and treatment for Gulf War Illness in a clinical setting,  while working directly with veterans. VHA also provides funding to  intramural researchers, many of whom are physicians employed by the  VA healthcare system.
In 1998, legislation was enacted that required VA to seek to enter into an  agreement with the National Academy of Sciences to study topics related  to Gulf War Illness. Since 2000, the National Academy of Medicine has  published a series of reports related to Gulf War Illness that review the  scientific and medical literature regarding the associations between  illnesses, and exposure to toxic agents, environmental or wartime  hazards, and preventative medicine or vaccines associated with Gulf War  service. Recommendations from these reports are submitted to the  Secretary of VA for consideration.
In 2002, VA established a Research Advisory Committee on Gulf War  Veterans’ Illnesses to provide advice and make recommendations to the  VA on proposed Gulf War Illness research studies, plans, and strategies.  This Committee convenes members appointed by VA, including veterans,  veterans’ advocates, and members of the medical and scientific  communities both within and outside of VA, and it holds public meetings  to discuss topics related to VA’s Gulf War Illness research. Since its  inception, the Research Advisory Committee on Gulf War Veterans’  Illnesses has produced more than a dozen reports and made many  recommendations to the Secretary of VA on the agency’s Gulf War Illness  research activities. In 2004, due in part to continued concerns and  additional Department of Defense reports of hazards and toxins Gulf War  veterans may have been exposed to during their deployment, we reported  on the status of federal research and investigations into Gulf War  illnesses, and found that the federal Gulf War Illness research strategy  needed reassessment. Since that time, VHA developed a Gulf War  Research Strategic Plan, which was last updated in 2015, to guide its  overall priorities for Gulf War Illness research.
According to VA and a 2016 National Academy of Medicine report, while  much progress has been made in Gulf War Illness research, more work  remains to be done to understand the health effects from Gulf War  service, as well as the specific causes and potential treatments. The  National Academy of Medicine noted that this is, in part, because military  records—including deployment, vaccination, and exposure records—can  be unreliable, which results in researchers oftentimes having to rely on  self-reported data, which is susceptible to memory failings and recall  bias. In addition, nearly 30 years have passed since the beginning of  the Gulf War, and it is becoming harder to distinguish between the effects  of Gulf War Illness on veterans’ bodies and the normal aging process. For  example, many illnesses associated with Gulf War Illness, such as joint  pain, fatigue, and memory problems, are common in the general  population and can also be associated with aging. In October 2016, VA  cited the continued scientific uncertainty surrounding the causes and  symptoms of the illnesses suffered by Gulf War veterans when it  extended the time frames in which medical issues can manifest for the  purposes of receiving disability compensation from the end of 2016 to the  end of 2021.
section_title: In Recent Years, Completed Gulf War Illness Claims Have Risen, Included More Medical Issues, and Been Approved at Lower Rates Than Other Service-related Disabilities
subsections: section_title: The Number of Completed Gulf War Illness Claims Generally Increased from Fiscal Years 2010 - 2015
paragraphs: The number of Gulf War Illness claims VBA completed more than  doubled from about 4,800 in fiscal year 2010 through 2015, increasing  from to 11,400 during this time. Our analysis of VBA claims data  revealed that VBA completed about 42,000 Gulf War Illness claims in  total during fiscal years 2010-2015. These claims included nearly  75,000 undiagnosed illnesses, 27,000 medically unexplained chronic  multisymptom illnesses, and 400 infectious diseases.
At the same time, however, the number of completed claims with Gulf  War Illness medical issues—specifically those for medically unexplained  chronic multisymptom illnesses—may be underreported due to unclear  guidance and inconsistent data entry over time by VBA’s claim rating  staff. According to VBA officials, medically unexplained chronic  multisymptom illnesses are only identified in the database as Gulf War  Illness-related if VBA claim raters identify them as such. Several claim  raters and VBA officials told us that staff had not been consistently  identifying these medical issues as Gulf War Illness-related. In July 2016,  during the course of our review, VBA officials told us they updated  guidance to clarify that claims raters should use existing Gulf War Illness- related codes to record their rating decisions about medically unexplained  chronic multisymptom illnesses in the VBA database. They said this  clarification is intended to improve tracking of these medical issues  moving forward.
We found that the approval rate for the group of potentially unidentified  medically unexplained chronic multisymptom illness medical issues was  nearly identical to the approval rate for those that VA had identified as  Gulf War Illness medical issues. We tested the data to determine the  potential magnitude of the underreporting in the number of Gulf War  Illness-related chronic multisymptom illness medical issues and found  approximately 57,000 that may not have been identified in VBA’s data as  Gulf War Illness-related medical issues. According to officials, VBA is  not planning to correct these data from prior years, but it acknowledges  the importance of tracking Gulf War Illness medical issues better in the  future and expects that the updated guidance will improve future  reporting.
section_title: Gulf War Illness Claims Included More Medical Issues and Took Longer to Complete
paragraphs: In each year from fiscal years 2010 through 2015, Gulf War Illness claims  averaged about twice the number of medical issues (about nine per  claim) than all other claims completed (about four). A medical issue is an  illness or condition that a veteran alleges was caused or worsened by  their military service and may entitle them to disability benefits. A veteran  can submit a claim that includes multiple medical issues that they would  like VBA to evaluate for disability compensation purposes. VBA claim  rating staff review each medical issue on a claim to make a determination  to award or deny benefits to the veteran.
While the processing time to evaluate each medical issue may vary,  claims with more medical issues typically take longer to complete. From  fiscal years 2010-2015, Gulf War Illness claims took about 4 months  longer for VBA to complete than all other types of claims, averaging about  1 year compared to about 8 months from date of filing to completion. The  time to complete all claims began to decrease in 2014 (see fig. 4).
According to VBA, the decline in the average number of days to complete  a claim may be due in part to the transformation plan it fully implemented  in fiscal year 2013, which, among other things, introduced new paperless  technology for processing disability claims more quickly. While the  average time for VBA to complete a claim decreased across the board in  fiscal years 2014 and 2015, our analysis of VBA’s data during this time  period shows that Gulf War Illness claims completed in fiscal year 2015  still took 270 days to complete, on average, which is more than twice as  long as VA’s goal of 125 days from claim initiation to completion.
section_title: Approval Rates for Gulf War Illness Medical Issues Were Three Times Lower Than for Other Types of Medical Issues
paragraphs: Our review of VBA data shows that during fiscal years 2010-2015 the  approval rate for Gulf War Illness medical issues was 17 percent (about  18,000 of 102,000 issues rated), which was about 3 times lower than all  other medical issues at 57 percent (about 14 million of 24.7 million issues  rated). This approval rate was consistently lower than that of the non- Gulf War Illness medical issues in each year we reviewed, which officials  attributed, in part, to the complexity of processing Gulf War Illness-related  medical issues. Nonetheless, according to VBA officials, many of the  veterans with denied Gulf War medical issues had other related medical  issues approved, and, as a result, many veterans still received some  disability compensation from VA.
Approval rates for Gulf War Illness medical issues varied by type of  illness. From fiscal years 2010 through 2015, VBA’s approval rate  averaged approximately 13 percent for undiagnosed illness medical  issues, 29 percent for medically unexplained chronic multisymptom illness  medical issues (which may include fibromyalgia, chronic fatigue  syndrome, and functional gastrointestinal disorders), and 14 percent for  medical issues related to certain infectious diseases (which may include  malaria, mycobacterium tuberculosis, and West Nile virus, among others).  Approval rates for medically unexplained chronic multisymptom illness  medical issues and undiagnosed illness medical issues decreased from  fiscal year 2010 to fiscal year 2015, while approval rates for infectious  disease medical issues increased during this period (see fig. 5).
These Gulf War Illness medical issues may be denied at a higher rate, in  part, because according to VA officials, Gulf War Illness is not always well  understood by VA staff, and veterans sometimes do not have the medical  records to adequately support their claims.
section_title: Accurate Processing of Gulf War Illness Claims Is Hampered by Confusion about the Gulf War General Medical Exam, and Claim Decision Letters Lack Key Information
subsections: section_title: VA Has Improved Some of Its Gulf War Illness Guidance, but Weaknesses Remain in Training on Conducting Gulf War General Medical Exams
subsections: section_title: Requesting a Gulf War General Medical Exam
paragraphs: The Gulf War general medical exam can be used to help determine a  veteran’s entitlement to VA disability benefits. According to VBA  guidance, the Gulf War general medical exam must be requested when  there is evidence of a chronic disease and qualifying service in Southwest  Asia. For example, if a veteran’s claim includes medical records that  show the veteran has made complaints that fall under the undiagnosed  illness or chronic multisymptom illness categories, a Gulf War general  medical exam should be requested. VBA has taken steps to clarify  when its staff should request these examinations to support Gulf War  Illness disability claim decisions. VBA provides guidance to its claims staff  regarding when to request this medical exam; however, we found  different interpretations of the guidance among staff in the four regional  offices we visited. VBA officials acknowledged that the guidance on when  to order a Gulf War general medical exam was complicated and said that  each claim is unique and staff are expected to use their professional  judgment on when to request exams. Confusion regarding the guidance  for VBA staff on the exam process was further revealed through two VBA  Special Focus Reviews on Gulf War Illness claim denials conducted in  2015 and 2016. These reviews found incorrect claim decisions related  to the medical exam process, including VBA claims’ staff failing to obtain  medical exams when they were necessary to properly evaluate a  veteran’s claim.
In response, VBA implemented training for its staff nationwide, which  among other things covered when to request a Gulf War general medical  exam. In addition, a VBA official said they will administer a consistency  study to claims processing staff in the 3rd quarter of fiscal year 2017 that  will focus on when to request a Gulf War general medical examination.  This consistency study should provide VBA with additional information  about the effectiveness of its training for claims rating staff and identify  any areas for additional improvement.
section_title: Conducting and Reporting on the Gulf War Medical Exam
paragraphs: In addition, several VHA medical examiners we interviewed said that they  can face challenges responding to the VBA’s guidance that accompanies  the Gulf War general medical exam request. VBA’s Notice to Examiners  asks medical examiners to evaluate a veteran’s symptoms and determine  if the symptoms are due to an undiagnosed illness or a medically  unexplained chronic multisymptom illness or related to a known diagnosis  or illness. Several VHA medical examiners told us it can be challenging to  determine whether veterans’ symptoms are undiagnosed illnesses and  medically unexplained chronic multisymptom illnesses, which would put  them in category (1) or (2) and would presume they are related to service  in the Southwest Asia theater of operations. Medical examiners have  different views on and approaches for how to assess veterans for  undiagnosed illnesses, in part, because of the challenge of identifying  something as an undiagnosed or unexplainable illness. For example, two  examiners said that to determine that a veteran should be categorized as  having an undiagnosed illness, they would have to rule out all known  diseases that could cause the veterans symptoms. Doing so, however, is  beyond the scope of a medical exam for disability compensation  purposes. The purpose for such an exam is to provide VBA with the  medical information it needs to decide a disability claim, rather than to  diagnose and treat illnesses. Medical examiners at one clinic told us that  they could nearly always attribute a veteran’s symptoms to a diagnosable  illness, which would mean the veteran does not qualify for benefits under  the undiagnosed illness presumptive category. According to our analysis  of VBA data, in fiscal year 2015, eight VBA regional offices had approval  rates of 5 percent or less for undiagnosed illness medical issues. For  additional data on regional office approval rates, see appendix II.
According to several VBA claim rating staff we interviewed, VHA medical  examiners sometimes provide a medical opinion related to service  connection when one is not necessary because the veteran has a  presumptive condition, which fall into categories (1) and (2) and are  considered Gulf War illnesses. This opinion may include language that  indicates the veteran’s presumptive condition may not be related to their  service. If VBA claim raters do not recognize that the medical examiner  has provided an unnecessary medical opinion about service connection  for a presumptive condition, they may inadvertently deny a claim that  should be presumptively granted. In our claim file review, we found two  cases where the VHA medical examiner provided a medical opinion  related to service connection for presumptive conditions.
VHA developed specific training for medical examiners who may conduct  these exams, and since June 2015, VHA has offered this optional 90- minute web-based training course. We found this course on Gulf War  Illness exams covers topics some medical examiners said were  challenging. For example, the training course covers when a medical  opinion from VHA on potential service connection is not needed to  support these claims. However, only a few of the medical examiners we  spoke with recalled having completed this training. At the same time,  several VA staff noted the complexity of Gulf War Illness claims and some  medical examiners stated they would benefit from additional training on  Gulf War Illness and how to conduct these exams.
According to a VHA official, as of February 2017, VHA’s training data  shows that only about 10 percent of its medical examiners had completed  this optional Gulf War Illness course. According to a VHA official, the low  participation rate may be due to high workloads and the limited amount of  time medical examiners are allowed for elective training. VHA medical  examiners must complete several mandatory training courses when they  are first hired, before they are permitted to perform medical exams. In  addition, they must complete training courses before performing certain  specialty medical exams, such as for traumatic brain injury or post- traumatic stress disorder. VHA’s Directive on Training and Certification of  Clinicians Performing VA Disability Examinations states that training is  critical to ensure clinicians who conduct medical examinations: (1)  understand that disability examination reports have legal ramifications  and (2) understand what VBA needs to know to make a valid  determination on disability claims. In addition, federal internal control  standards state that carrying out assigned responsibilities requires  knowledge, skills, and abilities, which are gained through training, among  other things. Without training, medical examiners may not be able to  reliably and consistently carry out their responsibilities with regard to  conducting and reporting on Gulf War general medical exams and provide  adequate information for decision-making to VBA’s claim rating staff.
section_title: Decision Letters to Veterans Regarding Their Gulf War Illness Claims Do Not Always Include Important Information
paragraphs: VBA guidance on preparing decisions on disability compensation claims  instructs staff to explain all methods of service connection considered  when denying a claim. If VBA determines that a veteran’s Gulf War Illness  claim does not meet the requirements for either a direct or presumptive  service connection, a letter is sent to the veteran stating that the claim  was denied. However, VBA’s decision letter denying benefits for Gulf War  Illness claims does not separately explain each method of service  connection that was considered. Rather, these letters simply include more  general language about service connection and explain that VA was not  able to link the veteran’s medical condition to their military service.
This may make it appear as if VBA is denying the claim without  considering it for service connection under a presumptive method. For  example, in one Gulf War Illness claim file we reviewed, nowhere in the  decision letter does VBA explain that the claim for sleep disorder—one of  the symptoms of undiagnosed illness and medically unexplained chronic  multisymptom illness—due to Gulf War Illness was evaluated for service  connection under both a direct and a presumptive method. See excerpt  from one denial letter we reviewed, below (emphasis added):  “Service connection for sleep disorder is denied since this condition  neither occurred in nor was caused by service.
Service connection may be granted for any disease or injury that is considered to  have resulted in a period of war or service. To establish direct service connection  for a claimed disorder, objective evidence must show a diagnosis of a current  disability that is related to a disease or injury incurred in or aggravated during  "active" service; or that manifested itself to a compensable degree within one  year from the date of discharge. The evidence does not show an event,  disease or injury in service. Your service treatment records do not contain  complaints, treatment, or diagnosis for this condition. The evidence does not  show a current diagnosed disability. We received your medical evidence which  discusses the symptoms of your medical condition. We did not find a link  between your medical condition and military service.”
The language in the above letter could lead the veteran to conclude that  their claim was denied because VBA was unable to establish a link  between their medical condition and their service in the Gulf War and that  VBA had not considered it under the presumptive method of service  connection. Without also including clear language in the decision letter  about VBA’s inability to grant service connection for their claim under the  presumptive method, veterans may be uncertain that this was the case  and may be unable to make a fully informed decision on whether to  appeal VBA’s decision. VBA regulations state that claimants are entitled  to notice of a VA decision that affects their benefits, including a clear  statement of the reason, or reasons, for the decision. VA is currently  reviewing its decision letters as part of a broader review of the appeals  process, and it has noted that veterans need a clear and detailed notice  when a claim is decided. However, this effort does not include a review of  the decision letters for Gulf War Illness claims. In its draft framework for  the appeals process, VA identifies eight elements of an adequate notice  to veterans. These elements include language in plain English that  informs the veteran of VA’s findings including an explanation of how the  evidence was considered.
section_title: VA Considers Research When Identifying Additional Disabilities Related to Gulf War Service, but It Lacks a Plan to Guide Its Work on Key Research Goal
subsections: section_title: VA Has Used Research to Establish Presumptive Medical Conditions for Gulf War Veterans
paragraphs: VA’s research on Gulf War Illness is used in several ways including  identifying symptoms, diagnosing those with illnesses, developing  treatment, and finding methods to respond to similar illnesses that may  arise among veterans in the future. Some of this research is directly  relevant to the disability compensation program; for example, it has been  used to establish additional presumptive conditions. To determine if new  presumptive conditions should be established, VA contracts with the  National Academy of Medicine, which forms a committee, to review all  Gulf War Illness-related medical and scientific information. For each  topic VA would like to study, it gives to a committee of the National  Academy of Medicine a specific topic and the committee reviews current,  related peer-reviewed research and hears from relevant experts and  stakeholders in public meetings. The committee writes a report to the  VA Secretary that may include recommendations, such as adding  potential illnesses to the list of presumptive conditions, or suggested  areas for future Gulf War Illness research. Officials from VA’s Office of  Research and Development and Post-Deployment Health review and  consider recommendations from the committee when determining if  research evidence warrants an expansion of the list of symptoms or  illnesses that are considered presumptively connected to Gulf War  service (see fig. 6). VA then adds new presumptive illnesses or other  medical issues that VA will provide disability compensation for through  regulations, and such illnesses can also be added through legislation.
One recent example of using evidence-based research occurred in 2010  when VA amended its regulation to establish nine infectious diseases as  additional conditions presumed to be connected to Gulf War service. VA  officials told us the agency did so as a result of evidence presented in a  2006 National Academy of Medicine Gulf War and Health report on the  relationship between Gulf War service and the manifestation of certain  infectious diseases. VA follows a similar internal review process when it  considers recommendations or suggested presumptive conditions  brought to it from other stakeholders, such as veterans advocacy groups  or the Research Advisory Committee on Gulf War Veterans’ Illnesses.
VA has not identified any new presumptive conditions that it associates  with Gulf War service since adding the nine infectious diseases in 2010,  but agency officials say they continue to review research, analyze  National Academy of Medicine report findings and recommendations, and  work with stakeholders to identify whether additional illnesses should be  added. For example, according to VA officials, a stakeholder group  recently worked with VA leadership to consider adding brain cancer to the  list of presumptive conditions associated with service in the Gulf War.  After further consideration, VA officials said the agency decided not to  proceed, citing limited scientific evidence from a 2016 National Academy  of Medicine report. To inform the potential inclusion of brain cancer on  the list of presumptive conditions in the future, VA officials told us that the  agency will ask the upcoming National Academy of Medicine committee  to include in its next review more recent research, including VA research,  that has been completed since the National Academy of Medicine’s prior  study on brain cancer incidence in Gulf War veterans.
section_title: Lack of a Plan to Establish a Single Case Definition of Gulf War Illness Hinders VA’s Progress toward Achieving This Goal
paragraphs: VA’s progress toward its goal of establishing a single case definition of  Gulf War Illness is hindered by the lack of a plan to undertake this work.  As noted earlier, to help inform its Gulf War Illness research activities, VA  relies on input from two key advisory groups—the National Academy of  Medicine and VA’s Research Advisory Committee on Gulf War Veterans’  Illnesses. In 2014, these groups each recommended that VA take steps  to establish a single case definition of Gulf War Illness that can be  uniformly used to describe symptoms related to Gulf War service.  According to the Centers for Disease Control and Prevention, a case  definition is a set of uniform criteria used to define a disease for public  health surveillance. VA’s advisory groups emphasized the importance of  a single case definition to improve the research, clinical diagnosis, and treatment of Gulf War Illness in veterans. In the past, researchers have  used multiple definitions to characterize symptoms in Gulf War veterans,  and VA currently uses two different definitions of Gulf War Illness for its  research. According to VA, this has limited the extent to which  researchers can compare findings between studies and identify similar  characteristics of the illness.
Both the National Academy of Medicine and VA’s Research Advisory  Committee on Gulf War Veterans’ Illnesses noted that a single case  definition would help advance Gulf War Illness research activities by  ensuring they are more focused and their results more usable. To make  progress toward this goal, both groups recommended VA analyze data  from its existing datasets in the near-term to better understand how they  can be used to contribute to a case definition while also conducting future  research projects that contribute to this goal in the long term.  Specifically, VA has access to dozens of existing large-population  datasets from federally sponsored research studies, as well as data  contained in several federal Gulf War registries that include veterans’  health information. According to VA, if these data were merged with its  administrative datasets, the information could be leveraged by VA  researchers to improve understanding of Gulf War Illness and, ultimately,  contribute to the development of a single case definition. These datasets  could provide researchers with additional information needed to develop a  case definition, including information on veterans’ service and onset of  their symptoms. VA’s research advisory groups also noted the long-term  need for VA to plan for future research that is likely to contribute to a  single case definition. In its Gulf War Research Strategic Plan, VA noted  that future research might include the application of new scientific  capabilities, such as biomarker identification and genome-wide  association studies that could not only significantly advance  understanding of an individual’s genetic pre-disposition toward developing  symptoms of Gulf War Illness, but also help to inform the establishment of  a single case definition.
In response to recommendations from its advisory groups to establish a  single case definition of Gulf War Illness, VA included this as a strategic  objective in its 2015 update to the Gulf War Research Strategic Plan.  However, according to a VA official, the agency has not developed a plan  to guide its review of existing medical datasets or integrate information  from recent and ongoing research to identify areas of future research and  establish a single case definition. Federal internal control standards call  for agencies to have documented plans that include specific action steps  associated with their objectives. VHA officials told us that they are  considering how to use existing federal datasets and ongoing research to  better understand Gulf War Illness but have not laid out specific actions,  such as what data to use and how using these data would contribute to  the development of a single case definition. VA officials attributed the lack  of a specific plan to challenges with developing a single case definition  and noted that it must be a slow and deliberate process. However,  without a plan, VA risks engaging in research activities that are not  cohesively targeted toward its goal. Planning for additional research to  establish a single case definition could lead to improvements in the  diagnosis and treatment of veterans with Gulf War Illness.
section_title: Conclusions
paragraphs: Nearly 30 years after the Gulf War conflicts began, hundreds of  thousands of veterans continue to experience chronic medical conditions  that may be related to a host of hazardous exposures they faced while  serving our country in Southwest Asia and Afghanistan. Since VA first  began to provide disability compensation to veterans suffering from Gulf  War Illness in 1995, the agency has improved aspects of its guidance and  training to help its staff accurately and consistently process Gulf War  Illness claims. Nevertheless, VHA’s medical examiners have expressed  confusion about how to conduct and report on the Gulf War general  medical exam. By not requiring training on Gulf War Illness for its  examiners, VA runs the risk of inconsistently and inaccurately making  benefit decisions.
When VBA denies a veteran’s Gulf War Illness claim, it is important that  the reason(s) be completely and clearly explained. Particularly for  complex claims such as Gulf War Illness, which can be evaluated through  both a presumptive and direct service connection, veterans should be  able to understand what VBA decided and why. Decision letters that lack  important information about how a claim was evaluated and decided may  lead the veteran to conclude that VBA had not considered their claim  under the presumptive method of service connection.
Finally, the persistent lack of a single case definition for Gulf War Illness  contributes to many of the current challenges with the Gulf War Illness  disability compensation program. VA has made significant progress on  Gulf War research in the past 27 years, but much work remains to be  done. Without a documented plan to establish a single case definition, VA  may miss opportunities to focus its efforts and advance knowledge about  Gulf War Illness, and potentially improve the lives of hundreds of  thousands of affected veterans.
section_title: Recommendations for Executive Action
paragraphs: To help ensure VHA medical examiners are prepared to conduct the Gulf  War general medical exam, we recommend that the Secretary of  Veterans Affairs direct the Under Secretary for Health to require medical  examiners to complete training, such as the 90-minute Gulf War Illness  web-based course, before conducting these exams.
To provide more complete information to veterans whose Gulf War Illness  claims are denied, we recommend that the Secretary of Veterans Affairs  direct the Under Secretary for Benefits to update guidance to require that  decision letters indicate whether Gulf War Illness medical issues were  evaluated under both a presumptive and direct service connection  method.
To increase the likelihood of making progress toward developing a single  case definition of Gulf War Illness, we recommend that the Secretary of  Veterans Affairs direct the Under Secretary for Health to prepare and  document a plan to develop a single case definition of Gulf War Illness.  This plan should include near- and long-term specific actions, such as  analyzing and leveraging information in existing datasets and identifying  any areas for future research to help VA achieve this goal.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to the Department of Veterans Affairs  for review and comment. Their comments are reproduced in appendix III.  VA agreed with all of our recommendations and stated it has plans in  place to address them. Regarding training on Gulf War Illness for its  medical examiners, VA said it plans to make its 90-minute web-based  training course mandatory for its medical examiners who conduct Gulf  War Illness exams. VA also stated it will improve how it communicates  decisions to veterans and is in the process of updating its guidance to the  regional offices to clarify the language required for its Gulf War Illness  decision letters. Finally, VA said it will convene a group of subject matter  experts to work on a plan—as described in our report—to establish a  single case definition of Gulf War Illness.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the appropriate  congressional committees, the Secretary of Veterans Affairs, the Under  Secretary for Health, and the Under Secretary for Benefits. In addition,  the report will be available at no charge on the GAO website at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (617) 788-0534 or emreyarrasm@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix IV.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: The objectives of this report were to examine (1) the trends in Gulf War  Illness disability claims in recent years, (2) challenges associated with  accurately processing and clearly communicating decisions on Gulf War  Illness disability claims, and (3) how the Department of Veterans Affairs  (VA) uses research on Gulf War Illness to inform its disability  compensation program. To address all three objectives, we reviewed  relevant federal laws and regulations as well as VA policies, procedures,  guidance, training materials, and VA documents describing its Gulf War  Illness research program. We also reviewed federal standards for internal  controls. Further, for all three objectives, we interviewed Veterans  Benefits Administration (VBA) and Veterans Health Administration (VHA)  officials, regional staff, and several veterans’ advocacy organizations.
We conducted this performance audit from October 2015 to June 2017 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.
subsections: section_title: Analysis of VA Data on Gulf War Illness Trends
paragraphs: To examine recent trends in Gulf War Illness disability claims, we  obtained and analyzed administrative data from VBA’s Veterans Service  Network Corporate Database for claims completed in fiscal years 2010  through 2015 (the most recent data available at the time of our review).  The data contained information on veterans’ service that included dates  of service, branch of service, medical issues the veteran had ratings for,  and whether the veteran served in the Southwest Asia theater of  operations during the Persian Gulf War. It also contained information on  rating decisions (approvals and denials) and award information for all  disability claims, including Gulf War Illness claims. The Gulf War Illness  claim trends we present are of veterans who were deployed to Southwest  Asia since August 2, 1990, because service in the Southwest Asia theater of operations (or Afghanistan, in the case of certain infectious diseases) is  required to be granted these benefits presumptively.
We requested data on claims completed in fiscal years 2010 through  2015 because in 2010 VBA established specific codes in its database to  track medical issues for Gulf War Illness disability claims. To identify Gulf  War Illness claims in the data, VBA created three separate indicator fields  in the dataset provided to us, one for each of the three types of  presumptive Gulf War illnesses (undiagnosed illnesses, chronic  multisymptom illnesses, and infectious diseases). To verify that VBA’s  Gulf War Illness indicator fields were complete per VBA’s definition, we  performed a reliability check by comparing the diagnostic codes  associated with each rating decision to the Gulf War indicator VBA  provided. Unless otherwise noted, we relied on VBA’s Gulf War Illness  indicator fields to conduct our analysis of Gulf War Illness claim trends.
We assessed the reliability of the data we used in our analysis by (1)  performing electronic testing for obvious errors in accuracy and  completeness, (2) reviewing existing information about the data and the  system that produced them, and (3) interviewing agency officials  knowledgeable about the data. We determined that the data were  sufficiently reliable for purposes of providing information on trends found  in Gulf War Illness claims. However, there were limitations to the data we  obtained. Specifically:
The data may under-represent the number of Gulf War veterans who  were deployed to Southwest Asia. VBA officials stated that these data  may not include some Gulf War veterans who were deployed to the  region after June 2008 because, according to VBA officials, the  agency does not always verify military service records on deployment  locations. According to VBA officials, the most reliable source of  deployment data is from the Department of Defense. To identify  veterans who served in the Gulf War conflicts, VBA used a  Department of Defense personnel file containing deployment  information. According to VBA officials, VA last received a copy of this  file in June 2008, and they do not consider the information on  veterans’ service locations to be complete after this date.
The data on the medically unexplained chronic multisymptom illness  medical issues may have been underreported due to inconsistent data  entry over time by VBA’s claim rating staff. According to VBA officials,  the three primary chronic multisymptom illnesses (chronic fatigue  syndrome, fibromyalgia, and functional gastrointestinal disorders) can  be disabilities claimed by any veteran regardless of when and where  they served. We counted the number of medical issues without a VA  Gulf War Illness flag for the three diagnostic codes for chronic  multisymptom illnesses from eligible Gulf War veterans to determine  the number of possible under-reported Gulf War Illness-related claims  for medically unexplained chronic multisymptom illness.
We did not evaluate if service connection was properly considered in  the Gulf War Illness claims we analyzed. According to VBA, it is  impossible to determine from the data alone if service connection was  properly considered under relevant federal laws and regulations  because there are a limited number of denial options in its database.
section_title: Review of Gulf War Illness Claims Processing
paragraphs: To understand challenges associated with accurately processing and  clearly communicating decisions on Gulf War Illness disability claims, we  reviewed relevant federal laws, regulations, and VBA’s procedures  manual. We also reviewed two internal assessments conducted by VBA  of the accuracy of a random sample of denied Gulf War Illness claims, as  well as a review of claims processing staff’s responses to standardized  questionnaires on developing and rating claims involving disabilities  associated with Gulf War service. We assessed the reliability of these  documents by interviewing agency officials knowledgeable about how  they were produced and determined that they were sufficiently reliable for  the purposes of our reporting objectives. We conducted interviews with  VBA and VHA headquarters officials and officials at four regional offices  (selected based on high numbers of Gulf War Illness claims completed in  fiscal year 2015 and to obtain geographic dispersion). The four regional  offices were Cleveland, Ohio; Seattle, Washington; St. Petersburg,  Florida; and Waco, Texas. These offices were in the top quarter of VBA’s  regional offices in terms of the number of undiagnosed illness and  medically unexplained chronic multisymptom illness claims completed in  fiscal year 2015. Two of these offices had approval rates above the  median approval rate and the other offices’ approval rates were below the  median. We also interviewed officials at four VHA compensation and  pension examination clinics associated with these regional offices.
During our VBA site visits, we interviewed VBA claims processing and  quality review staff, management, and local veterans service organization  officials. We discussed VBA’s procedures for processing Gulf War Illness  claims, including requests for Gulf War general medical exams and  challenges related to that process. At the VHA clinics, we interviewed  VHA medical examiners, supervisors, and administrative staff. Where  available, we also interviewed VBA staff assigned as liaisons to the VHA  clinic to troubleshoot issues related to compensation and pension  examinations. With these staff, we discussed the medical exam process  for Gulf War Illness claims and related challenges. We obtained and  reviewed regional office documents related to Gulf War Illness claim  processing, including locally developed training and guidance designed to  assist VBA staff responsible for processing Gulf War Illness claims. In  addition, we reviewed a sample of 44 Gulf War Illness files for claims  completed in fiscal year 2015 to provide illustrative examples of how VA  evaluates claims for Gulf War Illness and communicates its decisions to  veterans. For each file, we reviewed the veteran’s application for  disability benefits, the VA Gulf War general medical exam request and  report, the VBA rating decision and coding sheet, and the decision letters  sent to the veteran by VBA. The interviews we conducted and the claim  files we reviewed are non-generalizable, though they provided illustrative  examples of the challenges VA staff face when processing Gulf War  Illness claims.
section_title: Role of Research in Understanding Gulf War Illness
paragraphs: To assess how VA uses research on Gulf War Illness to inform its  disability compensation program, we reviewed reports and  recommendations from the National Academy of Medicine (formerly the  Institute of Medicine) and VA’s Research Advisory Committee on Gulf  War Veterans’ Illnesses about Gulf War Illness research, as well as  internal tracking documents used by VA to follow the implementation  status of related recommendations. We also reviewed strategic planning  documents for VA’s Gulf War Illness Research Program. In addition, we  reviewed reports from VA’s prior internal Gulf War Illness task forces and  workgroups and interviewed officials about the impetus for and outcomes  of these efforts. We interviewed officials from the VA Office of Policy and  Planning and from VHA’s Offices of Research and Development and  Post-Deployment Health to discuss past and future Gulf War Illness  research priorities and how research findings inform the disability  compensation program. We also interviewed current and former members  of the Research Advisory Committee on Gulf War Veterans’ Illnesses, the  study director for the Gulf War and Health series at the National Academy  of Medicine’s Health and Medicine Division, and the officials responsible  for Gulf War Illness research at the Department of Defense’s  Congressionally Directed Medical Research Programs. Our interviews  with these individuals focused on the current state of Gulf War Illness  research and VA’s process for planning and conducting Gulf War Illness  research.
section_title: Appendix II: Approval Rates for Gulf War Illness Medical Issues Completed in Fiscal Year 2015 by Veterans Benefits Administration Regional Office
paragraphs: The following table includes our analysis of Veterans Benefits  Administration (VBA) administrative data on all 58 regional offices’  approval rates for medically unexplained chronic multisymptom illness  and undiagnosed illness medical issues completed by VBA in fiscal year  2015.
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Nyree M. Ryder Tee (Assistant  Director), Nora Boretti (Analyst-In-Charge), Daniel Bertoni, Kaitlan M.  Doying, John Lack, and Martin E. Scire made significant contributions to  this report. Also contributing to this report were James E. Bennett,  Deborah K. Bland, Melinda L. Cordero, Brett S. Fallavollita, Alexander G.  Galuten, Michael P. Hartnett, Lara L. Laufer, Marcia A. Mann, Jeffrey M.  Mayhew, Sushil K. Sharma, Almeta J. Spencer, Walter K. Vance, and  Kathleen L. van Gelder.
section_title: Related GAO Products
paragraphs: Waste Management: DOD Has Generally Addressed Legislative  Requirements on the Use of Burn Pits but Needs to Fully Assess Health  Effects. GAO-16-781. Washington, D.C.: September 26, 2016.
Department of Veterans Affairs: Federal Gulf War Illnesses Research  Strategy Needs Reassessment. GAO-04-767. Washington, D.C.: June 1,  2004.
Gulf War Illnesses: DOD’s Conclusions About U.S. Troops’ Exposure  Cannot Be Adequately Supported. GAO-04-821T. Washington, D.C.:  June 1, 2004.
Gulf War Illnesses: Federal Research Efforts Have Waned, and Research  Findings Have Not Been Reassessed. GAO-04-815T. Washington, D.C.:  June 1, 2004.
Veterans Benefits Administration: Clarity of Letters to Claimants Needs to  Be Improved. GAO-02-395. Washington, D.C.: April 23, 2002.
Veterans’ Benefits: Improvements Made to Persian Gulf Claims  Processing. GAO/T-HEHS-98-89. Washington, D.C.: February 5, 1998.
Gulf War Illnesses: Improved Monitoring of Clinical Progress and  Reexamination of Research Emphasis Are Needed. GAO/NSIAD-97-163.  Washington, D.C.: June 23, 1997.
Veterans’ Compensation: Evidence Considered in Persian Gulf War  Undiagnosed Illness Claims. GAO/HEHS-96-112. Washington, D.C.: May  28, 1996.