| Citation |
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Post Deployment Health Evaluation
and Management. Washington, DC: Office of Quality and Performance
and the Veterans Affairs and Department of Defense Development Work
Group, Veterans Health Administration, Department of Veterans Affairs;
February 2001. OQP publication 10Q-CPG/PDH-01.
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Completion Date:
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February 2001 |
Release Date:
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September 2001
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| Source(s): |
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The Post-Deployment
Health Evaluation and Management
Guideline was developed by and written for clinicians by clinical
experts from the DoD, VHA, academia, a team of guideline
development specialists, and an experienced moderator who
facilitated the multidisciplinary panel. Internal Medicine, Family
Practice, Preventive and Occupational Health, Public Health,
Sports Medicine, Primary Care Physicians, Epidemiologists,
Surgeons, Psychologists, Psychiatrists, Nurses, Nurse
Practitioners, Physician Assistants, Quality and Risk Managers,
Risk Communicators.
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| Adaptation: |
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The DoD and Veterans Health Affairs
(VHA) convened a group of
experts, including the VHA Field Advisory Group and DoD Service
Champions nominated by each of the Surgeons General, to review
the Institute of Medicine (IOM)recommendations and develop a
plan for implementation. The challenge for the work group was to
develop an evidence-based post-deployment health clinical
evaluation program focused in the primary care setting. The group
consensus was to pursue the development of an evidence-based
clinical practice guideline (CPG) to assist clinicians in the primary
care setting in screening, evaluating, and managing the post-
deployment health concerns of service members and develop
specific treatment CPGs for those conditions recognized as most
important.
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| Guideline Status: |
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This is the current release
of the guideline. An update is targeted for 2003.
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| Developer(s): |
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Veterans Health Administration
(VHA), Department of Veterans Affairs (VA) - Federal Government Agency
[U.S.] Department of Defense (DoD) - Federal Government Agency [U.S.]
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| Funding Source: |
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United States Government
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| Committee: |
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Post-Deployment Health Evaluation and
Management Work Group
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| Group Composition: |
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list
of contributors
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| Disease Condition: |
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Post-Deployment Health Evaluation and
Management
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| Category: |
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Screening; Assessment;
Diagnosis; Evaluation ; Treatment; and Follow Up.
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| Intended Users: |
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Designed for use by primary
care providers. The guideline can also be used to coordinate, and
standardize care and as teaching tools for students and house staff.
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| Target Population: |
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Persons eligible for care
in the VA or DoD healthcare delivery system.
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| VHA Contact Person(s): |
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VHA :
Mark Brown, PhD
Director, Environmental Agents Service
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Ph: (202) 273-8579
Fax: (202) 273-9080
E-mail:
mbrown1@mail.va.gov
DoD:
Charles C. Engel, Jr., MD, LTC, MC, USA
Chief, Deployment Health Clinical Center
Walter Reed Army Medical Center
Building 2, Ward 64, Room 6441
6700 Georgia Avenue, NW
Washington, DC 20307
Ph: (202) 782-8064
Fax: (202) 782-3539
E-mail:
cengel@usuhs.mil
charles.engel@amedd.army.mil
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OBJECTIVES
- To promote evidence-based management of individuals
with post-deployment health concerns
- To identify the critical decision points
in management of patients with post-deployment health concerns
- To allow flexibility so that local policies
or procedures, such as those regarding referrals to or consultation
with specialists
- To improve local management of patients with
post-deployment health concerns and thereby improve patient outcome
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INTERVENTIONS AND
PRACTICES
The guidelines are meant to assist clinicians
in primary care settings in determining specific diagnoses for individuals
seeking care for potentially deployment related experiences or exposures.
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OUTCOMES CONSIDERED
Goals for individuals with post-deployment
health concerns is to focus care at the primary care level, both to
enhance the continuity of care and foster the establishment of ongoing
therapeutic relationships.
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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.
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CLINICAL ALGORITHMS
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TYPE OF EVIDENCE
The development process for the Guideline
was evidence-based whenever possible. Evidence-based practice integrates
clinical expertise with the best available clinical evidence derived
from systematic research. Where evidence is ambiguous or conflicting,
or scientific data are lacking, the clinical experience within the
multidisciplinary group guided the development of consensus-based
recommendations.
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DESCRIPTION OF
METHODS TO COLLECT EVIDENCE
The DoD and VHA asked the Institute of Medicine
(IOM) to evaluate the adequacy of the current clinical evaluation
programs for veterans of the Gulf War, since both evaluation programs
have evolved over time. The IOM Committees evaluating the adequacy
of the Gulf War Health Examination Registry (PGR), Uniform Case Assessment
Protocol (UCAP), and Comprehensive Clinical Evaluation Program (CCEP)
endorsed the systematic, comprehensive set of clinical practice guidelines
(CPGs) set forth in these diagnostic programs. In their report, Adequacy
of the Comprehensive Clinical Evaluation Program: A Focused Assessment,
the IOM Committee concluded, "The CCEP is a comprehensive effort
to address the clinical needs of the thousands of active duty personnel
who served in the Gulf War" (IOM, 1997). The CCEP and PGR have
assisted clinicians in determining specific diagnoses for thousands
of patients. However, the IOM emphasized the need to focus evaluation
and care of deployed forces at the primary care-level, both to enhance
the continuity of care and foster the establishment of ongoing therapeutic
relationships. In the report, Adequacy of the VA Persian Gulf Registry
and Uniform Case Assessment Protocol, the IOM further recommended
"…to the extent possible, use an evidence-based approach
to develop and continuously reevaluate clinical practice guidelines
for the most common presenting symptoms and the difficult-to-diagnose,
ill-defined, or medically unexplained conditions…" (IOM,
1998). Since research studies indicate a high prevalence of psychosocial
problems among deployed forces, the IOM recommended that standardized
guidelines address the need for screening, assessing, evaluating,
and treating this population. The IOM clearly stated that "the
goal of implementing a uniform approach to the diagnosis of …
veterans' health problems is admirable and should be encouraged"
(IOM, 1998). The IOM recommendations are based on research findings,
lessons learned through PGR and CCEP implementation, and advances
made in the field of clinical practice evaluation.
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METHODS TO ASSESS
THE QUALITY AND STRENGTH OF THE EVIDENCE
The literature was critically analyzed
with evidence grading. The rating scale used for this document was
based on the evidence rating used by U.S. Preventative Services
Task Force (http://text.nlm.nih.gov/cps/www/cps.3.html).
The Grading Scheme Used for the Guideline
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Quality
of Evidence (QE)
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| Grade |
Description |
| I |
Evidence
is obtained from at least one properly randomized controlled
trial. |
| II-1 |
Evidence
is obtained from well-designed controlled trials without randomization.
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| II-2 |
Evidence
is obtained from well-designed cohort or case-control analytic
studies, preferably from more than one center or research group. |
| II-3 |
Evidence
is obtained from multiple time series with or without the intervention.
Dramatic results in uncontrolled experiments could also be regarded
as this type of evidence. |
| III |
Opinions
of respected authorities are based on clinical experience, descriptive
studies in case reports, or reports of expert committees. |
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Strength
of Recommendation (SR)
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| Grade |
Description |
| A |
There
is good evidence to support the recommendation that the condition
be specifically considered. |
| B |
There
is fair evidence to support the recommendation that the condition
be specifically considered |
| C |
There
is insufficient evidence to recommend for or against the inclusion
of the condition, but a recommendation may be based on other
grounds. |
| D |
There
is fair evidence to support the recommendation that the condition
be excluded from consideration |
| E |
There
is good evidence to support the recommendation that the condition
be excluded from consideration |
Recommendations were
based on evidence published in the medical literature.
The literature supporting
the decision points and directives in the Guideline is referenced
throughout the document. Prior to a review of the literature, the
work group leaders provided input on focal issues.
A search was carried
out using the National Library of Medicine's (NLM) MEDLINE database.
Boolean "AND" expressions were used in conjunction with
the targeted MEDLINE Medical Subject Headings (MeSH) "descriptor"
categories, including but not limited to, those listed below:
- Anxiety
- Mental disorders,
including anxiety and depression
- Pharmacotherapies
- Fatigue syndrome
- Fibromyalgia
- Medically unexplained
symptoms
- Multiple chemical
sensitivities
- Post-Traumatic Stress
Syndrome
- Post War Risk Factors
MeSH "qualifiers"
(e.g., meta-analysis), were also utilized to request specific types
of publications, such as peer reviewed journals and tutorials, using
two discreet query delimiters:
- Articles published between 1996 and 1999,
with some exceptions
- English language only
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