We suggest that current models of psychological distress based solely on discrete traumatic events m

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-and- DoD-VA CLINICAL PRACTICE GUIDELINE
ONPOST-DEPLOYMENT HEALTH EVALUATION MANAGEMENT
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Objectives

• Describe the purposes of the DoD-VA clinical
  practice guideline on post-deployment health care
• Summarize the basic features of the guideline and
  strategies to facilitate its implementation
• Discuss future directions for implementation
  efforts and measurement of guideline adherence

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Why Focus On Post-Deployment Health
Care?(Isnt it just routine health care in a
slightly different uniform?)
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because our workplace may be hazardous to
health.
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The Gulf War

• Half-million troops
• Halfway around the globe
• Decisive military victory
• Low rates of DNBI
• Fewest associated deaths of any U.S. war

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A Unique Phenomenon?Post-War Post-Deployment
Syndromes

• Poorly understood war syndromes have been
  associated with armed conflicts since at least
  the US Civil War.
• war syndromes have involved fundamental,
  unanswered questions about chronic somatic
  symptoms

Hyams et al. Ann Intern Med 1996125398
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Sequelae of WarHistory Made Overly Simple

• Before VietnamLife Limb
• After VietnamPost-Traumatic Stress Disorder
• After Gulf WarToxic Exposure ConcernsMedically
  Unexplained Symptoms

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Recent Unexplained Syndromes Involving the
Military, War, Deployment, or Terror

• Dutch peacekeepers in Lebanon (1980s)
• Jungle Disease (Dutch peacekeepers in Cambodia)
• Gulf War Syndrome
• Afghanistan Syndrome (Russia, 1990s)
• Chechnya Syndrome (Russia, 1990s)

• Illnesses after 1992 El Al Airliner crash in
  Amsterdam
• Illnesses after anthrax vaccination (1990s)
• Dutch peacekeepers in Bosnia (1995-6)
• Canadian peacekeepers in Croatia (late 1990s)
• Balkan War Syndrome

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A Unique Phenomenon?
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The beat goes on
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Unexplained Physical SymptomsMedicines Dirty
Little Secret

• Specialty Clinical SyndromeOrthopedics Low Back
  Pain Patellofemoral Syndrome
• Gynecology Chronic Pelvic Pain Premenstrual
  Syndrome
• ENT Idiopathic Tinnitus
• Neurology Idiopathic Dizziness Chronic Headache
• Urology Chronic Prostatitis Interstitial
  Cystitis Urethral Syndrome
• Anesthesiology Chronic Pain Syndromes
• Cardiology Atypical Chest Pain Idiopathic
  Syncope Mitral Valve Prolapse
• Pulmonary Hyperventilation Syndrome
• Endocrinology Hypoglycemia

• Specialty Clinical Syndrome Dentistry Temporomand
  ibular Disorder
• Rheumatology Fibromyalgia Myofascial
  Syndrome Siliconosis
• Internal Medicine Chronic Fatigue Syndrome
• Infect Disease Chronic Lyme Chronic Epstein-Barr
  Virus Chronic Brucellosis Chronic Candidiasis
• Gastroenterology Irritable Bowel
  Syndrome Gastroesophogeal Reflux
• Physical Medicine Mild Closed Head Injury
• Occ Medicine Multiple Chemical Sensitivity Sick
  Building Syndrome
• Military Medicine Gulf War Syndrome
• Psychiatry Somatoform Disorders

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Physical Symptoms, Provider Beliefs,
Interpretive Space

• The large problematic gap between what is
  proven what is plausible in clinical practice
• Proof a very high test
• Plausible a very low test
• Stress unpredictable meanings

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Richardson, Engel et al. Archives of Internal
Medicine 2001 1611289-94
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Richardson, Engel et al. Archives of Internal
Medicine 2001 1611289-94
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Institute of Medicine

• Strategy 5 Implement strategies to address
  medically unexplained physical symptoms in
  populations that have been deployed.

WA, DC, National Academy Press 2000
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How Can We Do Better?
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The Broader Goal Collaborative Management

• Collaborative provider-patient definition of
  problems
• Negotiated targeting, goal setting, and planning
• Medical importance of the problem
• Patient motivation and readiness for self-care
• Continuum of support services and self-management
  training
• Sustained, active follow-up

Von Korff et al, Ann Intern Med,
19971271097-1102
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Toward Collaborative Post-Deployment Health Care

• practice guidelines and clinical information
  systems
• performance indicators and incentives
• science-based technical assistance
• stakeholder involvement in effort to improve care

Von Korff et al, Ann Intern Med,
19971271097-1102
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DoD Centers for Deployment HealthASD(HA) Policy
Letter 30 Sep 1999

• Consistent with Section 743 of the Strom
  Thurmond National Defense Authorization Act,
  1999, IoM, PRD-5
• Deployment Health Clinical Center at Walter
  Reed Army Medical Center
• Deployment Health Research Centerat Naval Health
  Research Center in San Diego
• Deployment Health Surveillance Centerat Center
  for Health Promotion Preventive Medicine

Abbreviated as DHCC
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DHCC Mission

• Improve post-deployment health care for DoD
  beneficiaries and reservists

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How Do We Get There From Here?

• Clinical experience
• Clinically relevant evidence
• Evidence-based practice guidelines
• Guideline implementation
• Pragmatic studies of implementation
• Recursive cycle

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DHCC Mission Concept
CPG DoD/VA Post-Deployment Health Evaluation
Management Clinical Practice Guideline
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Science-Based Technical Assistance

• DHCC provides post-deployment expertise in
• Health service delivery
• Health service informatics, education,
  communication
• Health services research

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DoD-VA CLINICAL PRACTICE GUIDELINE
ONPOST-DEPLOYMENT HEALTH EVALUATION MANAGEMENT
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Thanks To Contributing Agencies

• Office of the Assistant Secretary of Defense for
  Health Affairs
• US Army MEDCOM Quality Management Directorate
• US Army Center for Health Promotion Preventive
  Medicine
• RAND Corporation
• Pilot Implementation Sites
• Flight Medicine, McGuire Air Force Base
• Department of Family Practice, Womack Army
  Medical Center, Fort Bragg, NC
• 2nd Marine Division HHQ BASCamp LeJeune Naval
  Air Hospital-Family Practice.

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Post-Deployment CPG Concept Development

• Fulfills recommendations two IoM panels
• DoD VA assessments for Gulf War veterans
• Force Health Protection
• Concept derived from collaboration of DoD and VA
  clinical experts in April 1998
• Briefed approved
• Deputy Assistant Secretary of Defense for Health
  Affairs
• Chief Public Health Environmental Hazards
  Officer

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Post-Deployment CPG Concept Development
(Contd)

• Field tested for six months
• Fort Bragg
• Camp Lejeune
• Maguire Air Force Base
• Start-up implementation 1 Feb 2002
• Full implementation 1 July 2002
• Serves as clinical backbone for the for
  post-deployment health care

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Overview of Guideline Features

• Military-unique vital sign
• Stepped care framework
• Risk communication guidance
• Web-based clinician support
• Longitudinal care emphasis
• Data automation features
• Metrics outcomes monitoring
• Supporting center of excellence

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Guideline StructureThree Clinical Modules

• Assessment of Post-Deployment Health Concern
• Decision and Triage of the Patient With
  Unexplained Symptoms
• Management of the Patient with an Established
  Diagnosis

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Military Unique Vital Sign

• Is your visit today related to a deployment?
  (yes-no-maybe)
• all contacts except wellness visits (e.g.,
  periodic examinations, preventive care)
• patient rather than clinician determination
• lt 1 of patients say yes

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Stepped Risk Communication
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Visit for Deployment Related Concern

• ICD-9-CM visit code v70.5_ _6
• Definition A visit used to evaluate, clarify,
  treat, or provide information regarding one or
  more patient or provider based post-deployment
  health concerns.
• This code does not necessarily establish or
  imply causality between any of the providers
  diagnoses and any particular deployment.

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The Asymptomatic Patient with Health Concerns

• Expresses a health concern, but does not exhibit
  or describe any discernable illness or injury
• Concerns related to
• Illness
• Exposure
• An experience
• News media coverage
• Another information source
• ICD-9-CM code v65.5 plus v70.5_ _6

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Medically Unexplained Symptoms (MUS)

• Physical symptoms that provoke care-seeking, but
  have no clinically determined pathogenesis after
  an appropriately thorough diagnostic evaluation.
• IDC-9-CM MUS Code - 799.8 plus v70.5_ _6

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ICD-9-CM Coding for Identifiable Disease

• usual disease codeplus v70.5_ _6

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PDHealth.milWorld Wide Web Support for
Post-Deployment Health Care

• Designed For Federal Civilian Clinicians,
  Soldiers, Their Families

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http//www.PDHealth.mil

• For Clinicians
• For Veterans Families
• About this Site
• Education and Training
• Related Sites/Links
• Glossary Acronyms

• Guidelines
• Guideline Broadcast
• Help FAQs
• Site Map
• Contact DHCC

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Self-Help Information Tools
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Health Assessments(Tools available at
www.PDHealth.mil)

• Medical Exposure Assessment
• Short Form 36 version 2 (SF-36v2) A short
  measure of health-related quality of life.
  Applicable to patients with any health condition
  or concern. PDHealth.mil offers web-based
  administration scoring.
• Patient Health Questionnaire (PRIME-MD) A rapid
  measure of common, disabling, and treatable
  mental disorders for clinical use in primary care
  settings. Useful as a diagnostic and outcome
  assessment tool. Available on PDHealth.mil for
  downloading.
• Posttraumatic Stress Disorder Checklist (PCL) A
  brief measure of the cardinal symptoms of PTSD.
  Can be used for screening and longitudinal
  monitoring. Available on PDHealth.mil for
  downloading.

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Two Year Guideline Life Cycle
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A DoD Center of Excellence

• Deployment Health Clinical Center
• Specialized Care Program

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Local Challenges

• Identifying a local clinical administrative
  champion
• Local gap analysis
• Implementing the question?
• Adhering to visit coding?
• Assessing follow-up metrics?
• Local UM/Informatics support?
• Making provider patient information available
  from the tool kit?
• Obtaining risk communication training?
• DHCC News Medical Early Bird for those who
  want to know what patients may be reading

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Operation Solace - Bolstering Pentagon Services
After 9-11
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Please Contact Us!

• DoD Deployment Health Clinical Center 866-559-1627
  
• Walter Reed Army Medical Center 202-782-6563
• Building 2, Room 3G04 DSN 662
• 6900 Georgia Ave, NW pdhealth_at_na.amedd.army.mil
• Washington, DC 20307-5001