A New Era of Caring for Combat Veterans: Clinical

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A New Era of Caring for Combat Veterans
Clinical Research Activities of the War-Related
Illness and Injury Study Center Grand
Rounds December 6, 2002 VA Medical Center,
Washington, D.C.
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Genesis - Legislation

• Public Law 105-368 The Veterans Program
  Enhancement Act of 1998, Sec. 103
• National Center on War-Related Illnesses and
  Postdeployment Health Issues
• Secretary of Veterans Affairs report to Congress
• National Academy of Sciences recommendations
• NAS/IOM Committee, November 1999
• Committee on a National Center on War-Related
  Illnesses and Postdeployment Health Issues
• 9 member committee chaired by M Greenlick, MD,
  endorsed a VA plan similar in structure to GRECC

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Genesis - Timeline
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Mission Statement
To improve the health of combat veterans through
clinical care, risk communication, education, and
research addressing deployment related exposures
and the risk of latent illness, injury and
disability.
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WRIISC-DC Organization
Medical Center Director Sanford M. Garfunkel
Chief of Staff Ross D. Fletcher, MD
Director, WRIISC-DC Han K. Kang, DrPH
Clinical Care
Risk Communication
Education Outreach
Research
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WRIISC-DC Conceptual Model
Education Outreach
Research
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WRIISC-DC Staff Directory
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Collaborators
George Washington University Paul H. Levine,
M.D. Samuel J. Simmens, Ph.D. Johns Hopkins
University Barbara Curbow, Ph.D. Genevieve M.
Matanoski, M.D., Dr. P.H. Peter St. John Lees,
Ph.D. Department of Defense Center for Health
Promotion and Preventive Medicine (CHPPM) Jack
M. Heller, Ph.D. Mark Rubertone, M.D.,
M.P.H. Walter Reed Army Medical Center
(WRAMC) Charles C. Engel, M.D., M.P.H. David N.
Cowan, Ph.D. Uniformed Services University of the
Health Sciences (USUHS) David H. Trump, M.D.,
M.P.H. Gary Gackstetter, DMV, Ph.D.
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Potential Wartime Exposures

• Malnutrition
• Endemic infectious diseases
• Psychological stressors
• Climatic exposures
• Toxic or noxious agents
• Poor hygiene

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Common Post-Deployment Health Complaints Among
Gulf War Veterans

• Headache, 54
• Unrefreshing sleep, 47
• Anxious, 45
• Joint pain, 45
• Fatigue, 38
• Heartburn, 37
• Difficulty sleeping, 37
• Depressed, 36
• Difficulty concentrating, 35

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Summary
Eight FTEEs 1.1M Core Funding per Year Serves as
one of the two inpatient referral centers for
war-related illnesses injuries Funding renewal
after 3 years To create a center of excellence
for research, education, risk communication and
clinical care in deployment-related illness and
injury
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Clinical Care Objectives

• Develop innovative clinical strategies for
  war-related illnesses
• Develop effective education techniques for the
  clinical setting
• Implement clinical algorithms into primary care
  settings for evaluation of veterans with
  war-related illnesses

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Clinical Care Program

• Referral source for veterans with war-related
  health concerns and difficult to diagnose
  war-related illnesses and injuries
• Examine, manage, and provide consultation
  services to veterans with war-related illnesses
  and injuries
• Two major clinical care programs
• WRIISC National Referral Program
• WRIISC Outpatient Clinic

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National Referral Program

• Designed for veterans with difficult to diagnose
  war-related illnesses and injuries outside
  driving distance to Washington, DC
• The program serves as a focused second opinion
  evaluation for veterans with war-related concerns

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Distribution of WRIISC Referrals
WRIISC-NJ VISNs 1-4
WRIISC-DC VISNs 5-8
Referrals from remaining VISNs are alternated
between the WRIISCs
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WRIISC Outpatient Clinic

• Specialty clinic for outpatient referrals with
  war-related concerns, illnesses, or injuries.
• Initial evaluation will serve to direct further
  care within VAMC or collaborative clinics.
• Clinic will help coordinate specialty referrals
  and ultimately refer the veteran back to his/her
  primary medical provider for follow-up.

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Clinical Program Interface
Medical Service Specialties
Social Work Service
Rehabilitation
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Clinical Measures

• SF-36v General Health Survey
• Physical Well Being
• Mental Well Being
• Patient Satisfaction Survey
• Management Recommendations

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Clinical Resources

• EEG/EMG Lab
• Sleep Lab and EEG Monitoring Beds
• Neuropsychology Lab
• Magnetic Stimulation Lab
• Multidisciplinary Pain Treatment Program
• MRI
• NRH Specialty Clinic
• WRAMC Deployment Health Clinical Center
• Specialty Consultative Services

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Clinical Status Report

• Weekly outpatient clinic initiated in April 2002
  80 veterans evaluated
• Inpatient WRIISC referral program initiated in
  Jan 0216 completed
• Implementing DoD-VA Clinical Practice Guideline
  on Post-Deployment Health Evaluation Management
  within primary care environment

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Eligibility
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Eligibility

• New VHA patients must first contact the VAMC
  Eligibility Office
• All eligible veterans are assigned to a primary
  care provider, who may refer the veteran to the
  WRIISC Clinic
• Combat Service Veteran as defined by DoD
• Have unexplained symptoms felt to be associated
  with combat service or other deployment-related
  experience
• Medically and psychiatrically stable for travel
• Willing to participate in evaluation and
  treatment recommendations

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National Referral Program

• Referral to this inpatient program is through VA
  Central Office (Environmental Agents)
• Contact Helen Malaskiewicz, [phone]
• Referring physician to complete WRIISC Referral
  template on CPRS

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Outpatient Referral Process

• Referring provider completes CPRS WRIISC consult
• Upon receipt of consult, WRIISC-DC office
  schedules appointment for WRIISC Clinic
• Clinic hours Wednesday, 8am to 4pm
• Telephone numbers [phone], [phone]

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DoD-VA Clinical Practice Guideline on
Post-Deployment Health Evaluation Management

• Major Recommendations
• The guideline is presented in an algorithmic
  format and is intended to provide a systematic
  approach to the evaluation and management of
  patients with post-deployment health concerns.
• Clinical Algorithms
• A1 Assessment of Post-Deployment Health Concern
• A2 Decision and Triage of the Patient With
  Unexplained Symptoms
• A3 Management of the Patient with an Established
  Diagnosis

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Post Deployment Health Guidelines
www.pdhealth.mil
www.pdhealth.mil
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Risk Communication
A Definition
An interactive process of exchange of
information and opinion among individuals,
groups, and institutions. (p.2) National
Research Council, 1989
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Objectives
Risk Communication

• Provide the latest scientific information about
  the association between environmental exposures
  and war-related illnesses
• Assure understanding of relevant issues
• Support development of clinical treatment plan
• Provide reassurance, empathy, and caring
• LISTEN

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Risk Communication
Target Audience

• Veterans their families
• VAMC staff, medical and graduate students,
  residents
• Veteran Service Organizations

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Domains of Theory
Risk Communication
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The DHCC Clinically-Based Appropriately Stepped
Risk Communication Strategy
Model adapted from Dr. Charles Engel
(2002) Deployment Health Clinical Center
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Activities
Risk Communication

• Patient Interviews
• Inpatients
• Outpatients
• Research Program
• Needs Assessment
• Development of high tech applications
• Education

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Resource Room
Risk Communication

• Private space for patient interviews
• Access to print materials
• Computer access to internet resources and for
  computer based instruction

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Case Presentation

• 43-yr-old male Gulf War veteran with fatigue
  since 1992
• Environmental Exposure Concerns
• Oil Well Fires
• Depleted Uranium
• Pyridostigmine Bromide

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Medical History

• Fatigue Mild cardiac disease diagnosed in 1993
  while in the military
• Headache Brain cyst diagnosed in 1995 at
  community hospital by private MD
• Abnormal muscle CK found in 1995
• evaluated in local VA hospital
• Muscle biopsy sent to prominent labs 1995-96

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Diagnostic Impressions Prior to WRIISC Evaluation

• Probable CPT or Carnitine Deficiency
• Sensory Neural Hearing Impairment
• Brain Cyst
• Cardiovascular Disease
• Chronic Pain
• Low Testosterone
• Psychiatric Disorders
• Others

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Physical Exam

• General Mild cardiac murmur skin rashes, and
  mild gynecomastia
• Mental Status Depressed
• Cranial Nerve Sensory-neural hearing impairment
• Motor Proximal muscle atrophy, weakness
• Sensory impaired vibration on (R) lower leg
• Extrapyramidal and cerebellar system Normal

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WRIISC Assessment

• Medical Record Review
• Laboratory (Serum) Screening Study
• repeated CK level in resting conditions,
• forearm ischemic exercise test
• Nerve Conduction Study / EMG
• plan specific to relevant disease processes
• Review of muscle biopsy slides
• Consultation of Specialty Services
• VA
• Non-VA

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Diagnostic Summary

• Non-metabolic myopathy
• based on disease course
• persistent elevated CK (1500-4000 u)
• results of forearm ischemic exercise test
• Probable late onset Muscular Dystrophy
• Endocrinopathy
• low cortisol, low testosterone, high TSH
• Etiology for SNHL and cardiomyopathy are
  uncertain
• Comorbid psychiatric diseases

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Management Recommendations

• Convey clear messages e.g., patient does not
  have CPT deficiency (a metabolic myopathy)
• Muscular Dystrophy work-up is ongoing
• Endocrinopathy work-up at local VA hospital
• Education/Risk Communication for patient family
• his current specific illnesses
• exposures and how they relate to current diagnosis

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Lessons Learned

• Evolving disease process required an objective
  multidisciplinary evaluation
• Evaluation complicated by possible environmental
  hazard exposures
• Previous care providers unfamiliar with Gulf War
  related illness and injuries
• Best health outcome depends on multidisciplinary
  team knowledgeable about the health issues of
  combat veterans

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Objective
Research Program

• To investigate the health consequences of
  deployment in a combat theater with a specific
  focus on deployment-related exposures and the
  risk of latent illness, injury, and disability.

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Research Interests

• Health consequences of war
• Post service cause-specific mortality from
  diseases and injuries
• New or unusual infections
• Chronic medical and psychological conditions
• Adverse reproductive health outcomes
• Disability resulting from deployment illness or
  injury
• Health care utilization

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Health Assessment Gulf War Veterans
Health Care Utilization Inpatient Outpatient
Mortality Gulf 700,000 Controls 750,000
Health Registry PGR 70,000 CCEP 30,000
Population - Based Health Survey N 30,000
Phase I and II Mail or CATI Survey Medical
Records Review N21,000
State Tumor Registry DC, VA, MD, NJ
Combined VA/DOD Registry Analysis IOM/VA Pre-
Deployment Health Study
VA/DOD MVA Study
IOM/VA Nerve Gas Exposure Study
Phase III Clinical Study N2,000 CSP 458,
16 VAMCs
GW/VA Gulf War Syndrome Clinical Study
20 Year Longitudinal Health Study
Neuropsychologic Assessment Study
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Results Mortality Studies

• Overall mortality rate of Gulf War veterans is
  not higher than non-Gulf veterans.
• Mortality rates from injuries, especially motor
  vehicle crashes, were higher among Gulf War
  veterans than non-Gulf veterans
• Mortality rates for disease-related cases were
  lower among Gulf War veterans than non-Gulf
  veterans.
• These differences in mortality patterns began to
  dissipate 5 years after the war.
• Both Gulf and non-Gulf veterans mortality rates
  remained less than half that expected from their
  civilian counterparts.
• Both US and UK study results are remarkably
  similar
• Ref NEJM,19963351498 Am J
  Epi,1998149324 Am J Epi, 2001154399 Occup
  Environ Med, 2002, in print

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Health Care Utilization Findings

• No excess postwar hospitalization (1991-1994) due
  to major categories of diseases in VA, DoD and
  California hospital systems
• A small, yet significant, excess in
  hospitalization was observed among Gulf veterans
  due to mental disorders, diseases of respiratory
  system and the digestive system, diseases of
  skin, and other symptoms, signs and ill-defined
  conditions
• Ref NEJM,19963351498 Am J
  Epi,200015163

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National Health Survey Findings Phase I and II
I. Physical Health

• Gulf veterans reported higher prevalence of
• A wide variety of symptoms
• Health care utilization
• Serious chronic health conditions
• Lower perception of general health
• Functional impairment
• Ref J Occup Environ Med 200042491

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National Health Survey Findings Phase I and II
II. Psychological Health

• Gulf veterans reported higher prevalence of
  symptoms endorsing PTSD (PCL-M) and chronic
  fatigue syndrome (CDC 1994)
• The prevalence of PTSD increased monotonically
  across 6 levels of deployment-related stress
  intensity (test of trend, p lt0.01)
• Gulf veterans reported higher rate of sexual
  trauma (harassment/assault) in theater, which in
  turn was associated with the higher prevalence of
  PTSD even after adjusting for the combat trauma.
• Ref Am J Epi,2002, in print

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National Health Survey Findings Phase I and II
III. Reproductive Health

• Gulf veterans reported higher rates of
• Miscarriage Male veterans OR1.62 95
  CI1.32-1.99 Female veterans OR 1.35
  95 CI 0.97-1.89
• Birth defects among liveborn infants
• Male veterans OR 1.78 95 CI1.19-2.66
• Female veterans OR 2.80 95 CI1.26-6.25
• Ref Ann Epi,200111504

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National Health Survey Findings Phase I and II
IV. Symptom Cluster

• A cluster of symptoms consistent with
  neurological impairment blurred vision, loss of
  balance/dizziness, tremors/shaking and speech
  difficulty
• The symptom complex appears to correlate with
  objective neurological abnormalities including
  abnormal ENG
• Relatively more symptomatic Gulf veterans were
  exposed to combat, engaged in military duties in
  Kuwait and Iraq, and potential nerve gas plume
  from Khamisiyah incident as determined by the
  Department of Defense
• Ref Arch Environ Health,20025761

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Current Studies

• Study of Fatal Motor Vehicle Crashes of Gulf War
  and Non-deployed Veterans
• Mortality and Morbidity Among U.S. Gulf Veterans
  Who Were Potentially Exposed to Nerve Gas at
  Khamisiyah, Iraq
• Health Outcomes of U.S. Veterans Who Were Pows
  During WWII or the Korean War
• Study of Health Outcomes Environmental
  Surveillance (SHOES) in Bosnia/Kosovo
• Longitudinal Health Study of Gulf War Era Vets

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Study of Health Outcomes Environmental
Surveillance (SHOES)in Bosnia/Kosovo

• Collaborators
• Army Medical Surveillance Activity
• Deployment Environmental Surveillance Program
• Specific Aims
• To develop a model data repository linking
  military service records and VA records
• To combine advancements in exposure assessment
  with health and illness experience to investigate
  the effects of deployment of armed forces
  personnel
• To explore topical research questions and
  validate findings of other veteran cohorts

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Study of Health Outcomes Environmental
Surveillance (SHOES) in Bosnia/Kosovo

• Application of SHOES
• Is there an excess mortality from MVC among B/K
  veterans as with other veteran cohorts?
• How were environmental exposures correlated with
  short long-term health outcomes?
• How do environmental monitoring data correlate
  with biomarker data?

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Longitudinal Health Study of Gulf War Era Vets

• PIs Han Kang, DrPH Seth Eisen, M.D., St. Louis
  VAMC
• Charles Engel Jr., M.D., WRAMC
• Study Design
• Longitudinal study of a permanent panel of 15,000
  Gulf veterans and an equal number of non-Gulf
  veterans identified for the National Health
  Survey.
• Specific Aims
• To determine the health status of Gulf War
  veterans relative to non-Gulf War veterans ten or
  more years after the war.
• To characterize how the health status of Gulf War
  and non-Gulf War veterans has changed in the past
  5 years.
• To compare the current health of Gulf War
  veterans with civilian peers.

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New and Proposed Studies

• Low Back Disorders and Long Term Consequences
• Cognitive Changes in Neurocysticercosis (NCC)
• Effectiveness of a Case Management Model (CMM) in
  Combat Service Veterans
• Health and Communications Survey of Veterans
• Prostate Cancer in Vietnam Veterans Development
  and Evaluation of Technology-based Approaches to
  Risk Communication
• Sleep Studies in Gulf War Veteran Patients With
  Multiple Symptoms

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Long Term Goals

• Establish cultivate collaborations with VA,
  DoD, academic researchers
• Secure funding for Investigator Initiated
  Research
• Establish WRIISC-DC as a resource for war-related
  illness injury research
• Further an understanding of the etiology and
  natural history of disease and injury in the
  veteran population

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Education Training Objective

• To educate health care providers about the risk
  factors, risk communication approaches,
  etiologies, diagnoses, and treatments associated
  with war related-illness injury.

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Education Training Target Audience

• VAMC house staff residents
• Medical and graduate students
• Veterans families
• Veterans Service Organizations

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Education TrainingApproaches

• Develop promote educational materials
• Veteran Health Initiatives
• Grand Rounds
• Service-specific presentations
• Establish a presence in the clinical research
  communities
• Sponsor participate in professional conferences
• www.va.gov/WRIISC-DC/
• Offer clinical research training opportunities
• Uniformed Services University research practicum
• Johns Hopkins Bloomberg School of Public Health

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Veterans Health Initiative  Independent Study
Courses
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Education Training Goals

• Establish WRIISC-DC as an educational resource
  for war-related illness injury
• Foster clinical recognition of appropriate
  treatment management of war-related aspects of
  illness injury (via clinical guidelines)
• Sponsor/co-sponsor educational forums on a
  monthly basis
• Establish contact with medical residents
  students

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WRIISC-DC Conceptual Model
Education Outreach
Research
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Questions?
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WRIISC Inpatient ReferralVeteran Profile
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WRIISC Outpatient ClinicVeteran Profile
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WRIISC Outpatient ClinicVeteran Profile