Adequacy of the VA Persian Gulf Registry and Uniform Case Assessment Protocol -- Copyright -- Preface -- Acknowledgments -- Contents -- Executive Summary -- FINDINGS AND RECOMMENDATIONS -- Diagnostic Process -- Implementation and Administration -- Referrals -- Quality -- Patient Satisfaction -- Data Collection and Reporting -- Outreach -- Provider Education -- SUMMARY -- 1 Introduction -- 2 The Institute of Medicine's Persian Gulf Activities -- 3 The Department of Veterans Affairs Persian Gulf Registry and Uniform Case Assessment Protocol -- PERSIAN GULF REGISTRY -- PHASE II: UNIFORM CASE ASSESSMENT PROTOCOL -- REFERRAL -- DATA COLLECTION AND REPORTING -- PERSONNEL -- PERFORMANCE MONITORING -- DESCRIPTIVE STATISTICS -- OUTREACH -- PROVIDER EDUCATION -- 4 Committee on the Evaluation of the Department of Veterans Affairs Uniform Case Assessment Protocol -- SITE VISITS -- WRITTEN TESTIMONY -- VA Health Facilities -- Veterans' Service Organizations -- 5 Findings and Recommendations -- DISCUSSION -- DIAGNOSTIC PROCESS -- IMPLEMENTATION AND ADMINISTRATION -- Referrals -- Quality -- Patient Satisfaction -- Data Collection and Reporting -- OUTREACH -- PROVIDER EDUCATION -- 6 Conclusion -- References and Selected Bibliography -- Appendix A Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate… -- FINDINGS AND RECOMMENDATIONS -- DATA AND DATABASES -- Finding I -- Recommendations -- Finding 2 -- Recommendation -- Finding 3 -- Recommendations -- COORDINATION/PROCESS -- Finding 4 -- Recommendation -- Finding 5 -- Recommendations -- CONSIDERATIONS OF STUDY DESIGN NEEDS -- Finding 6 -- Recommendations -- Finding 7 -- Recommendations -- Finding 8 -- Recommendation -- Finding 9 -- Recommendations -- Finding 10 -- Recommendation -- Finding 11 -- Recommendation -- Finding 12 -- Recommendation -- Finding 13.

Recommendations -- Finding 14 -- Recommendations -- Appendix B Health Consequences of Service During the Persian Gulf War: Recommendations for Research and Information Systems -- CHARGE TO THE COMMITTEE: ITS FINDINGS AND RECOMMENDATIONS -- Overview -- THE COMMITTEE'S CHARGE -- Charge 1 -- Charge 2 -- Charge 3 -- FINDINGS AND RECOMMENDATIONS -- Finding -- Finding -- Finding -- Finding -- Finding -- Finding -- Finding -- Finding -- Finding -- Finding -- Finding -- Finding -- Finding -- Appendix C Evaluation of the U.S. Department of Defense Persian Gulf Comprehensive Clinical Evaluation Program: Overall… -- 1.) OVERALL ASSESSMENT OF THE CCEP GOALS PROCEDURES -- 2.) GENERAL RECOMMENDATIONS FOR THE IMPLEMENTATION OF THE CCEP -- 2.1.) Referrals of Patients from Phase I to Phase II of the CCEP -- 2.1.1.) Structure and revise the CCEP protocol and logistics to allow the majority of patients to receive a final diagnosis… -- 2.1.2.) Curtail diagnostic work-ups in patients not seriously disabled with minor complaints -- 2.1.3.) Require additional efforts to provide more care at the primary care level -- 2.1.4.) Continue referral of subgroups of patients whose illnesses are difficult to diagnose -- 2.2.) Systematic Guidelines for Psychiatric Referrals and Adequacy of Psychiatric Resources -- 2.2.1.) Develop explicit guidelines for the identification of Phase I patients who would benefit from a psychiatric… -- 2.2.2.) Alert primary care physicians about the high prevalence of psychiatric disorders -- 3.) SPECIFIC OBSERVATIONS OF AND RECOMMENDATIONS FOR THE IMPLEMENTATION OF THE CCEP -- 3.1.) Analysis and Interpretation of the CCEP Results -- 3.1.1.) Symptoms and diagnoses in the CCEP population -- 3.1.1.1.) No evidence has been found that the DoD has been trying to avoid reaching a single unifying diagnosis.

3.1.1.2.) Signs and symptoms in many patients can be explained by well-recognized conditions -- 3.1.1.3.) Provide more detailed information on specific diagnoses in future reports -- 3.1.1.4.) Investigate the diagnosis in patients with disability processing actions -- 3.1.1.5.) Don't view CCEP results as estimates of the prevalence of disability related to Persian Gulf service -- 3.1.2.) Evidence of a New, Unique Persian Gulf Syndrome -- 3.1.2.1.) There is a lack of clinical evidence of a unique Persian Gulf Syndrome -- 3.1.2.2.) Share the entire CCEP data set with qualified researchers outside of the DoD -- 3.1.3.) Potential Relationship of Illnesses in CCEP Patients to Service in the Persian Gulf -- 3.1.3.1.) Discuss the issue of causality explicitly and unambiguously in its future reports -- 3.1.3.2.) Determine the timing of the onset of disease -- 3.1.4.) Comparison of the CCEP Population with Other Populations -- 3.1.4.1.) Be cautious about comparison with other populations -- 3.1.4.2.) It's difficult to establish causal relationships by relying on CCEP data alone -- 3.1.4.3.) Consider the CCEP data to have high clinical utility -- 3.2.) Specific Medical Diagnosis -- 3.2.1.) Psychiatric Conditions -- 3.2.1.1.) Make patients aware of psychiatric conditions and their prevalence and morbidity -- 3.2.1.2.) Emphasize effects and diagnosis of psychosocial stressors -- 3.2.1.3.) Identify people with risk of developing depression or Post-Traumatic Stress Disorder (PTSD) -- 3.2.1.4.) Improve standardization of psychiatric evaluations -- 3.2.1.5.) Document and investigate the onset and course of symptoms and psychosocial stressors -- 3.2.1.6.) Standardize neuropsychological evaluations -- 3.2.1.7.) Standardize classification and coding of diseases -- 3.2.1.8.) Document headache categories differently.

3.2.1.9.) Add explicit written instruction on medical record-keeping and coding -- 3.2.1.10.) Expand discussion of psychological stressors -- 3.2.1.11.) Utilize results of on-going studies to revise CCEP -- 3.2.2.) Musculoskeletal Conditions -- 3.2.2.1.) Provide more details of diagnostic categorization of musculoskeletal conditions -- 3.2.2.2.) Place more emphasis on musculoskeletal conditions -- 3.2.3.) Signs, Symptoms, and Ill-Defined Conditions -- 3.2.3.1.) Clarify types of disorders included in the ICD-9 category -- 3.2.4.) Infectious Diseases -- 3.2.4.1.) Infectious disease is not a frequent cause of serious illness -- 3.2.4.2.) Veterans are not likely afflicted with some previously unknown pathogen -- 3.2.5.) Chronic Fatigue Syndrome, Fibromyalgia, and Multiple Chemical Sensitivity -- 3.2.5.1.) Estimating prevalence of chronic fatigue syndrome, fibromyalgia, and multiple chemical sensitivity is difficult -- 3.2.5.2.) Collect data using established diagnostic criteria for CFS and FM -- 3.2.5.3.) Established diagnostic criteria do not exist for MCS -- 3.2.5.4.) Include CFS, FM, and MCS in on-going and future epidemiological research studies -- 3.2.5.5.) Continue thorough workup to diagnose sleep disturbances and fatigue -- 3.3.) Use of the CCEP Results for Education Improvements in the Medical Protocol and Outcome Evaluations -- 3.3.1.) Use of the CCEP Results for Education -- 3.3.1.1.) Continue public release of analysis results of the CCEP on an on-going, periodic basis -- 3.3.1.2.) Distribute CCEP findings to all primary care physicians at MTFs and RMCs -- 3.3.1.3.) Develop a more concise version of the DoD report for active-duty service personnel and veterans -- 3.3.1.4.) Develop a more comprehensive document describing potential exposures in more detail -- 3.3.2.) Use of the CCEP Results to Improve the Medical Protocol.

3.3.2.1.) Use CCEP examination results to improve standardization practices -- 3.3.2.2.) Refine questions related to potential psychological stressors -- 3.3.2.3.) Determine if lab tests or specialty consultations should be added to Phase I -- 3.3.2.4.) Compare and coordinate methods and clinical results of the CCEP and UCAP -- 3.3.3.) Use of the CCEP Results for Patient Outcome -- 3.3.3.1.) Perform targeted patient evaluations -- 3.3.3.2.) Communicate successful treatment methods between RMCs -- 3.3.3.3.) Review disorders among CCEP patients who have applied for disability payments or for medical discharge from the… -- 3.3.4.) Specialized Care Center (SCC) -- 3.3.4.1.) The DoD has made serious efforts to develop an SCC program that has ambitious goals -- 3.3.4.2.) Provide multidisciplinary treatment modalities -- 3.3.4.3.) Need for individualized follow-up and therapeutic regimens -- 3.3.4.4.) Develop objective measure of functional status for follow-up evaluation -- 3.3.4.5.) Evaluate the SCC program itself -- 3.3.4.6.) DoD has taken a serious approach to the treatment and rehabilitation of these patients in the SCC -- 3.3.4.7.) Investigate costs and benefits of the SCC program -- 3.3.4.8.) Identify the most effective elements of the SCC program -- 3.4.) Research Relevant to the CCEP -- 3.4.1.) Epidemiological Research Relevant to the CCEP -- 3.4.1.1.) Utilize on-going epidemiological studies for revising or improving the CCEP -- 3.4.1.2.) Acknowledge the serious limitations of the CCEP data for epidemiological purposes -- 3.4.2.) Exposure Assessment Research Relevant to the CCEP -- 3.4.2.1.) Investigate experiences of individuals in UICs with higher rates of CCEP participation -- 3.4.2.2.) Investigate exposures restricted to particular locations or special occupational groups.

COMMITTEE ON THE DOD PERSIAN GULF SYNDROME COMPREHENSIVE CLINICAL EVALUATION PROGRAM.