Adequacy of the VA Persian Gulf Registry and Uniform Case Assessment Protocol (1998) / Chapter Skim
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Executive Summary
Executive Summary
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developed a Persian Gulf Registry to assist in addressing questions about the health concerns of Persian Gulf veterans. Queries about exposures, particularly those associated with oil well fires, were included as part of the history taking.
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A great deal of time and a great deal of effort were expended by VA in developing and implementing a diagnostic program for Persian Gulf veterans that could be conducted in all VA facilities, from small rural primary care facilities to large urban tertiary complexes. This effort was begun immediately upon the cessation of hostilities and attempted to build on lessons learned from past program efforts, for example, those directed toward Vietnam veterans' health concerns.
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Such deviation introduces the problem of inconsistency in evaluations across facilities as well as variation in data recording and reporting. This failure, in turn, works against achieving one of the purposes for which the system was developed, Hat is, to identify previously unrecognized major diagnostic entities that could provide an explanation for the symptoms commonly reported in Persian Gulf veterans with unexplained illnesses (FA Manual M-10; see Chapter 3~.
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Pathway for diagnosing health problems of Persian Gulf veterans in the VA system.
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The pathway specifies an initial evaluation by a primary care provider for both the veteran presenting with complaints and those with no complaints. In traditional medical practice, the comprehensive clinical evaluation of a patient presenting to any physician includes a complete history, physical examination, and laboratory tests.
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conduct periodic reevaluations of the usefulness of each element in the initial evaluation. Specific Gulf War-related questions to which veterans are asked to respond include the exposure questions contained on the Persian Gulf Registry Code Sheet (see Appendix H)
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The information collected through that system as well as the information obtained from other providers and through scientific studies allows efforts to be more appropriately focused on identifying and diagnosing Persian Gulf veterans' health problems. One mechanism that can aid these efforts is the development of clinical practice guidelines which are statements developed for the purpose of assisting the provider and the patient in making decisions about appropriate health care.
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One approach to addressing this problem is the use of clinical pathways which are clinical management tools that organize, sequence, and specify the timing of the major patient care activities and interventions of the entire interdisciplinary team for a particular diagnosis, procedure, or process.
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The committee believes that, overall, the clinicians involved in the VA Persian Gulf Registry and UCAP examinations are practicing medicine according to acceptable standards but there does not appear to be, across facilities, a systematic approach to documenting the quality of care provided or to identifying areas where improvement is needed. Traditional quality improvement programs examined the structure within which care is provided, the process for providing care, or the outcomes of care in an attempt to identify the outliers or "bad apples." More recent approaches focus on performance improvement and are aimed at involving practitioners in the use of nonpunitive efforts that result in more effective changes and improvements to the system than was the case with approaches aimed at identifying practitioners with deficiencies.
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Outreach The committee commends VA for Me extensive effort it has put forth to inform Persian Gulf veterans of the services available to them. In only two areas has the committee identified needs.
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These pamphlets could be placed in facility treatment areas and could address common concerns such as the purpose and process of the VA Persian Gulf program, health effects of low-level exposure to chemical warfare agents, research activities related to Persian Gulf veterans and their results to date, and so forth. When first entering a VA health care facility to receive services, all veterans complete an intake form that requests infonnation about their service in the military.
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2. All patients entering the special VA program for Persian Gulf veterans should receive an expanded initial evaluation.
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6. VA should design and implement a brief yet comprehensive questionnaire to survey patient satisfaction with the special program for Persian Gulf veterans.
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It is with the intent to assist VA with better serving Persian Gulf veterans as well as facilitating the practice of VA practitioners that these recommendations are offered. The committee believes that the recommendations contained in this report will clarify areas of confusion and engage VA practitioners in efforts to design practice guidelines and pathways that will result in the rendering of better, more timely diagnostic services to Persian Gulf veterans.
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