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BACKGROUND/RATIONALE:
Numerous studies have shown that poorly defined medical conditions are commonly reported in the aftermath of military conflict. At least as far back as the American Civil War, soldiers have reported nonspecific ailments that could not be attributed to an underlying medical cause. The most frequent symptoms include persistent fatigue, palpitations, headache, muscle or joint pain, disturbed sleep, and cognitive difficulties. Recent epidemiologic studies suggest that war-related syndromes are exceptionally common in deployed personnel and may affect 45% to 60% of returning soldiers. Despite an uncertain etiology, these post-deployment symptoms have substantial consequences that include increased medical visitation, increased physical disability, and increased psychological distress. The fact that America is now engaged in military conflict abroad and threatened with weapons of mass destruction at home raises the possibility that a large number of veterans (and civilians) may eventually develop similar war-related illness. Unfortunately, the number of veterans at risk is likely to increase rather than decrease in the years ahead. In order to address this anticipated increase, new and more efficient treatments for symptom-based illness are urgently needed to augment or replace standard VA care. Fortunately, an effective treatment using cognitive-behavioral techniques (CBT) has been developed to ameliorate symptom-related distress and reduce unnecessary healthcare utilization. Despite convincing evidence of therapeutic efficacy, a major limitation of this treatment is that patients must attend sessions in person. This requirement may undermine the clinical effectiveness of CBT since fewer than half of those who need treatment are likely to attend. A recent trial of CBT for veterans with Gulf War Illness found that only 38% were treatment adherent. Any sudden increase in the number of veterans seeking care could overwhelm the limited resources of a local VA healthcare center. The proposed study will address this important public health problem by testing a cost-effective and innovative strategy for delivering CBT over the phone.
OBJECTIVE(S):
The specific aims of the study are to: (1) Determine the clinical efficacy of Telephone CBT for veterans with GWI who are frequent consumers of ambulatory medical care; (2) Determine whether CBT for veterans with GWI leads to a reduction in the cost of VA health care; and (3) Develop a statistical model of treatment seeking in veterans with GWI who are frequent consumers of ambulatory medical care.
METHODS:
Participation is limited to veterans who satisfy a validated case definition of GWI and whose utilization is at (or above) the 80th percentile. A long-term goal of the proposed research is to make specialized Telephone CBT services widely available to veterans regardless of their geographic location. A previously validated CBT program for GWI has been adapted in consultation with Dr. Charles Engel. The proposed study represents the first randomized (multicenter) trial of Telephone CBT designed to ameliorate GWI and reduce unnecessary reliance on VA health care services. A total of 150 eligible veterans will be assigned to one of three groups: (I) Telephone CBT + Customary Medical Care; (II) In-Person CBT + Customary Medical Care; or (III) Customary Medical Care only.
FINDINGS/RESULTS:
Revised study procedures were developed and approved by our local IRB. CBT manual was refined and adapted for telephone use. Two postdoctoral fellows were recruited, trained in CBT, and study assessment techniques. A large pool of high utilizing veterans was identifed. Of the first 1000 veteran names, 523 were not viable after chart review (outside catchment area; medical rule out; moved; deceased; etc); of 477 remaining 147 were not reachable; 102 declined; 46 were deemed ineligible after inital screening; 49 were eligible and scheduled for psychiatric interview. As of December 2006 a total of 116 veterans have been enrolled in the study and randomized to treatment.
IMPACT:
Given the prevalence of symptom-based illness and the likelihood that many of those affected may seek VA medical services, there is an urgent need to develop and test more cost effective methods of reducing unnecessary utilization. The development of a telephone intervention may benefit the VA by increasing readiness to treat veterans (and civilians) in the wake of military deployment, in the event of domestic terror attacks, or in the aftermath of war. We know that deployment and especially war-related trauma lead to increased care seeking in veterans with ill-defined or symptom-based medical illness. The proposed study is expressly intended to reduce unnecessary utilization of VA services while, at the same time, preserving or improving physical function, patient satisfaction and other quality of life indicators. If found effective, the treatment can be made readily available to veterans regardless of their geographic location. Long-term benefits may also include: lower costs for medical care; improved allocation of VA resources; improved quality of life; lower levels of psychiatric morbidity; and lower risk of iatrogenic injury.
PUBLICATIONS:
None at this time.
DRA:
Health Services and Systems, Military and Environmental Exposures
DRE:
Treatment, Resource Use and Cost
Keywords:
Cost effectiveness, Telemedicine, Gulf War I
MeSH Terms:
none
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