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Health and Human Services Department of Defense Veterans Affairs Health and Human Services Gulf War Information Department of Defense Gulf War Information Veterans Affairs Gulf War Information Home Home Advanced Search Glossary FAQs Site Map Contact Us
 Research Topics    |    Major Focus Areas
Research Topics
ACCIDENTS & INJURIES
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BRAIN & NERVOUS
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DIGESTIVE HEALTH
ENVIRONMENTAL & OCCUPATIONAL HEALTH
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GENETIC STUDIES
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IMMUNE/BLOOD SYSTEM
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General Health & Physical Symptoms
General
Project Summary

Title: Implementation and Evaluation of Gulf War Veterans' Demonstration Project (13)
Synopsis: This project established innovative clinical programs for Gulf War veterans in the VA medical centers Portland and Seattle.
Overall Project Objective: Gulf War veterans are important new users of VA services with unique medical problems. This project was designed to test innovative approaches with Gulf War veteran clinical programs at two large VA medical centers (in VISN 20, Portland VAMC and Puget Sound VAMC). These clinical programs, which offer primary care and case management services within an interdisciplinary primary care clinic, were tailored to meet the medical problems reported by some Gulf War veterans. The desired outcome was to correct problems in veterans' satisfaction with VA services as reported in previous studies.
Status/Results to Date: From the VISTA files for FY1998, 622 patients were identified at the Portland VAMC who had received clinical services, had Gulf War as VA period of service, and had Gulf War theater or combat service confirmed by DoD. This group comprised the initial Portland patient sample. For the Puget Sound site, the VISTA database of patients receiving services in FY1998 included 1,729 patients who had Gulf War combat or theater service verified by DoD records. Response rates were good for the mailed questionnaires in the three time periods. Patients returning questionnaires were representative of the larger population of VA patients at the two sites. Demographic characteristics of patients differed between the Portland and Puget Sound facilities, and there also were differences between the clinic and control populations at each site. Gulf War veterans receiving care at these sites tended to be under 40 years of age, male, Caucasian, and have education beyond high school. Puget Sound patients tended to be slightly older, more likely to be non-Caucasian, and less likely to be employed `full-time'. Portland patients receiving care in the Gulf War clinic were more likely than controls to be married and less likely to have education beyond high school. Seattle patients from the Gulf War clinic were less likely to be married and less likely to be employed full-time than the control group patients. Dissatisfaction with the VA compensation and pension (C&P) process among veterans who had applied was widespread. The Gulf War veterans in the clinic and control groups at both sites tended to report health status that was lower than general population norms, particularly for the vitality and general health perception scales from the SF36V. At both times 1 and 2, the Portland clinic group respondents did not have significantly different health status scores from control respondents. At time 3, mean health status scores were higher in Portland clinic respondents for all the SF36V scales except for the pain and mental health scales. These differences were greatest for the physical functioning, social functioning, and role-physical scales, however they did not reach statistical significance. In the Puget Sound VAMC, the clinic group patients had significantly lower SF36V scores than the control group patients for all three time periods. Other measures of psychological distress also were consistently worse among the Puget Sound clinic group patients. More than half of participating Gulf War veterans reported the same four types of health problems at both facilities. Portland Gulf War clinic patients had similar or slightly lower utilization and costs than the control group veterans seen in other VA clinics. Patients in the Puget Sound Gulf War clinic (located in Seattle) had significantly and consistently higher utilization and higher costs when compared with the control group patients. Most veterans reported that they would not use VA facilities if free care were available closer to home. Veterans also reported that the waiting time to receive prescription medications was too long. Finally, more than half of veterans who said they had needed medical help or advice right away felt that their problem should have been handled sooner. CONCLUSIONS: This study provided insight into the clinical status, health care experiences, and satisfaction of Gulf War veterans at two large VA medical centers. The two clinical care programs, based on different care models, attracted distinctly different patient populations. The mental health case management model at the Puget Sound program tended to attract veterans with high psychological distress. T he primary care delivery model at Portland attracted veterans with less severe health status impairments. Both programs served populations that were substantially impaired when compared to community norms of patients of a similar age range. The Puget Sound Gulf War Veterans' clinical approach was that aggressive intervention should encompass a comprehensive, integrated treatment strategy. Such interventions involve higher initial costs, which may be offset by decrements in management costs and diminished total expenditures resulting from decreased disability and enhanced function over time. The Portland Gulf War clinic patients had higher satisfaction with their VA medical care than control patients. This suggests that dedicated Gulf War veterans' clinics can improve perceptions of VA care for this group. Further studies are required to determine how durable and generalizable this finding is. The Puget Sound mental-health case management model required relatively greater medical care resources compared to the Portland primary care delivery model.
Project:VA-58
Agency:Department Of Veterans' Affairs
Location:VAMC Portland/Seattle
P.I. Name:David H Hickam, M.D.
Research Type:Clinical
Research Focus:Treatment
Focus Category:General Health & Physical Symptoms
Status:Complete
Study Start Date:July 01,1998
Estimated Completion Date:September 30,2000
Specific Aims: (1) Compare patient satisfaction, and physical and psychological functioning in Gulf War veterans who receive care from targeted clinical programs versus Gulf War veterans who receive care from other clinical sites in the two VA medical centers. (2) Evaluate the impact of carefully designed outpatient clinical programs on mean levels of physical and psychological functioning and satisfaction with VA care among selected Gulf War veterans receiving care at the two urban VA medical centers. (3) Assess and describe sources of dissatisfaction among Gulf War veterans who report problems with VA services they have received. (4) Examine whether satisfaction with VA services among Gulf War veterans is associated with demographic characteristics and levels of medical comorbidity and physical and psychological functioning. (5) Compare utilization of VA clinical services between Gulf War veterans in the targeted clinical program versus those who receive conventional VA care. (6) Evaluate the operating costs of the targeted clinical programs.
Methodology: The study design included two components. Component I was a prospective cohort study of all Gulf War veterans who received any VA services at either of the two participating medical centers during a twelve month period prior to implementation of the targeted clinical programs. Cohorts at each center (Portland and Puget Sound) were assessed at three time points during the course of the project (at months 4, 14, and 21). The targeted clinical programs for Gulf War veterans were implemented at month 6, following the first data collection. The members of the cohort were sub-divided into two groups: 1) patients who received services in the new targeted clinical programs (special care) and 2) those who did not receive services from the new programs (customary care) . The second component of the study compared all Gulf War veterans who used the new clinics to all Gulf War veterans who did not use the new clinics. Thus, Component 2 examined both patients who had used VA services prior to program implementation and patients who began using VA services after implementation. All of the members of the cohort used for Component 1 were included in Component 2. Essentially, Component 2 examined a larger number of patients than were enrolled in the cohort. As for Component 1, data collection for Component 2 was conducted at months 4,14 and 21. The additional patients used in Component 2 were identified from patient logs maintained by the clinics at both sites. Because the new users of VA services were not identified prior to program implementation, baseline data were not collected for them. However, questionnaire data (including verification of SW Asian service) on these veterans were collected at months 14 and 21. In this observational study, patients were not randomly assigned to the new clinics. Hospital staff were informed about the clinics, and patients were referred according to routine clinical care procedures. Patient data were surveyed using standardized questionnaires including the SF-36V, a comorbidity index previously developed in the VA, and the VA National Ambulatory Care Customer Satisfaction Survey. Cost and utilization data were collected using VISTA and DSS sources and the facilities' cost data report.
Most Recent Publications:

Richardson RD, Engel CC, Hunt S, McKnight K, McFall M. Are veterans seeking Veterans Affairs' primary care as healthy as those seeking Department of Defense primary care? A look at Gulf War veterans' symptoms and functional status. Psychosomatic Medicine, 64(4):676-683. Jul-Aug 2002. Abstract

Hunt S, Richardson RJ. Clinical Management of Gulf War Veterans with Chronic Multisymptom Illnesses. Conference on Illnesses among Gulf War Veterans. A Decade of Scientific Research, 2001. Presentation

Hickam DH, Joos SK. Demonstration project of alternative health care delivery models for gulf war veterans. Conference on Illnesses among Gulf War Veterans. A Decade of Scientific Research, 2001. Presentation

Richardson RJ, Tackett J, Maciejewski ML, Hunt S, McFall M. Predicting Costs of VA Health Care for Gulf War Veterans. Conference on Illnesses among Gulf War Veterans. A Decade of Scientific Research, 2001. Presentation