WASHINGTON — No “one-size-fits-all” approach should be used by the government to care for veterans with chronic multisymptom illness (CMI), the Institute of Medicine (IOM) recommended.
Instead, the Department of Veterans Affairs (VA) needs to craft an individualized management plan for their care, including establishing patient-aligned care teams (PACTs) specifically for veterans with CMI, the IOM said in a report released Wednesday.
“The condition is complex and not well understood, and it will require more than simply treating veterans with a set protocol of interventions,” stated the report, entitled “Gulf War and Health, Vol. 9.”
The IOM defined CMI — once called “Gulf War Syndrome” — as the presence of a range of chronic, medically unexplained symptoms experienced for 6 months or longer in at least two of six areas: fatigue, mood and cognition, musculoskeletal, gastrointestinal, respiratory, and neurologic.
The report described CMI as “a serious condition that imposes an enormous burden of suffering on our nation’s veterans.” Impairments include fatigue, joint and muscle pain, gastrointestinal complications, memory difficulties, depression, anxiety, and fibromyalgia.
Estimates peg CMI prevalence at about 25% to 35% of the 1991 Gulf War veterans — about 175,000 to 250,000 people. “Preliminary data suggest that CMI is occurring in veterans of the Iraq and Afghanistan wars as well,” the report stated. However, “there is no consensus among physicians, researchers, and others as to the cause of CMI … There is a growing belief that no specific causal factor or agent will be identified.”
The VA asked the IOM to conduct the study in August 2011 after Congress mandated it in the 2010 Veterans Benefits Act. The IOM committee, chaired by Bernard Rosof, MD, of Huntington Hospital in Huntington, N.Y., sought to find conclusions on and recommendations for treatment, as well as recommendations for the VA’s model of care.
The committee found that the best treatment for symptoms may be selective serotonin reuptake inhibitors, serotonin norepinephrine uptake inhibitors, and cognitive behavioral therapy.
Numerous programs the VA already has — including PACTs and War-Related Illness and Injury Study Center programs — to manage veterans with CMI have not been consistently implemented. Further, they haven’t been evaluated to learn their strengths and weaknesses in order to improve their quality, the committee found.
The IOM went on to recommend several specific ways the VA can improve the identification and treatment of those with CMI, including:
- Ensuring veterans complete a comprehensive health examination immediately upon leaving active duty.
- Including in the VA’s electronic health record (EHR) system a “pop-up” screen to prompt clinicians to ask questions about whether a patient has symptoms consistent with CMI.
- Developing patient-aligned care teams specifically for veterans with CMI. Teams should be well-resourced and patterned after those deemed to be centers of excellence.
- Developing a process for evaluating awareness among teams of professionals and veterans of its programs for managing patients with CMI.
- Providing required education and training for its clinicians in coordinating the care of veterans who have unexplained conditions, including CMI. This includes developing learning networks to introduce new information and skills related to managing veterans with CMI.
The IOM also recommended the VA develop “CMI champions” at each VA medical center to ensure clear communication and coordination among clinicians.
“In addition to using CMI champions to train clinicians about CMI, learning networks have been found to be effective tools for disseminating information,” the report said. “Continuous exchange of information among learning networks can lead to improved quality of care.”