Treatments for Chronic Multisymptom Illness

The committee conducted a de novo systematic assessment of the evidence on treatments for symptoms associated with CMI. The committee also identified evidence-based guidelines and systematic reviews on treatments for related and comorbid conditions (fibromyalgia, chronic pain, CFS, somatic symptom disorders, sleep disorders, IBS, functional dyspepsia, depression, anxiety, posttraumatic stress disorder, traumatic brain injury, substance-use and addictive disorders, and self-harm) to determine whether any treatments found to be effective for one of these conditions may be beneficial for CMI. Both pharmacologic and nonpharmacologic treatments were assessed. Holistic and integrative treatment approaches were considered in addition to individual interventions.

Studies of treatments for the symptoms associated with CMI conducted in the 1991 Gulf War veteran population were included in the assessment, as were studies conducted in different populations who had a similar constellation of symptoms. The generalizability of studies of nonveterans to veterans is not known.

The best available evidence from studies of treatment for symptoms of CMI and related and comorbid conditions demonstrates that many veterans who have CMI may benefit from such medications as selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors and cognitive behavioral therapy. On the basis of the evidence reviewed, the committee cannot recommend any specific therapy as a set treatment for veterans who have CMI. However, for the reasons outlined below, the committee believes that a “one-size-fits-all” approach is not effective for managing veterans who have CMI and that individualized health care management plans are necessary. The condition is complex and not well understood, and it will require more than simply treating veterans with a set protocol of interventions.

Recommendation 8-1. The Department of Veterans Affairs should implement a systemwide, integrated, multimodal, long-term management approach to manage veterans who have chronic multisymptom illness.

VA already has several programs—for example, postdeployment patient-aligned care teams (PD-PACTs), Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) programs, and the War-Related Illness and Injury Study Center (WRIISC) program—that could be used to effectively manage veterans who have CMI. However, the programs have not been consistently implemented through the VA health care system. Furthermore, the programs have not been adequately evaluated to learn about their strengths and weaknesses so that changes can be made to improve the quality of care.

Improving Care for Veterans Who Have Chronic Multisymptom Illness

The first step in providing care for veterans who have CMI is to identify them and to move them into VA's health care system so that they can receive proper care for their CMI and any common comorbidities.

Recommendation 8-2. The Department of Veterans Affairs (VA) should commit the necessary resources to ensure that veterans complete a comprehensive health examination immediately upon separation from active duty. The results should become part of a veteran's health record and should be made available to every clinician caring for the veteran, whether in or outside the VA health care system. Coordination of care, focused on transition in care, is essential for all veterans to ensure quality, patient safety, and the best health outcomes. Any veteran who has chronic multisymptom illness should be able to complete a comprehensive health examination.

Recommendation 8-3. The Department of Veterans Affairs should include in its electronic health record a “pop-up” screen to prompt clinicians to ask questions about whether a patient has symptoms consistent with the committee's definition of chronic multisymptom illness.

Once a veteran has been identified as having CMI and has entered the VA health care system, the next step is to provide comprehensive care for the veteran, not only for CMI but also for any comorbid conditions. VA has developed multiple clinical practice guidelines (CPGs) for medically unexplained symptoms and common comorbidities and conditions with shared symptoms; however, there is anecdotal evidence that simply adhering to multiple CPGs often is not effective for managing chronic conditions with multiple morbidities such as CMI and can result in incomplete care and increase the likelihood of overtreatment and adverse side effects. Rather, a unique personal care plan for each veteran is required for effective management of the health of veterans who have CMI.

VA's PD-PACTs, which use a team approach to providing coordinated, comprehensive, integrated care, should be able to provide care for veterans who have CMI if properly implemented. The move to the PACT model of care is relatively recent in VA's health care system, and implementation efforts are ongoing.

Recommendation 8-4. The Department of Veterans Affairs (VA) should develop patient-aligned care teams (PACTs) specifically for veterans who have chronic multisymptom illness (CMI; that is, CMI-PACTs) or CMI clinic days in existing PACTs at larger facilities, such as VA medical centers. A needs assessment should be conducted to determine what expertise is necessary to include in a CMI-PACT.

Recommendation 8-5. The Department of Veterans Affairs should commit the resources needed to ensure that patient-aligned care teams have the time and skills required to meet the needs of veterans who have chronic multisymptom illness as specified in the veterans' integrated personal care plans, that the adequacy of time for clinical encounters is measured routinely, and that clinical case loads are adjusted in response to the data generated by measurements. Data from patient experience-of-care surveys are essential to assist in determining needed adjustments.

Recommendation 8-6. The Department of Veterans Affairs should use patient-aligned care teams (PACTs) that have been demonstrated to be centers of excellence as examples so that other PACTs can build on their experiences.

To address the challenges of bringing care to veterans who lack easy access to VA medical centers, VA adopted SCAN-ECHO programs in 2010. SCAN-ECHO programs are being developed to bring specialty care to veterans who live in rural and other underserved areas. The SCAN-ECHO programs work by connecting clinicians who have expertise in particular specialties through video technology to provide case-based consultation and didactics to isolated primary care clinicians who would otherwise not have access to care for their patients.

Another VA program is the WRIISC program, which was established in 2001 to serve combat veterans who had unexplained illnesses. Veterans are generally referred to a WRIISC (there are three nationwide) by their clinicians when they are not improving and further local expertise is not available. Veterans in WRIISCs are evaluated by a multidisciplinary team that conducts a comprehensive health assessment and formulates a comprehensive personal care plan aimed at managing symptoms and improving functional health. Although WRIISCs have been in place for more than a decade, the committee does not have information on awareness of the program among the teams of professionals caring for veterans who have CMI or among the veterans themselves. Information also is lacking on the effectiveness of the program.

Recommendation 8-7. The Department of Veterans Affairs (VA) should develop a process for evaluating awareness among teams of professionals and veterans of its programs for managing veterans who have chronic multisymptom illness, including patient-aligned care teams (PACTs), specialty care access networks (SCANs), and war-related illness and injury study centers (WRIISCs); for providing education where necessary; and for measuring outcomes to determine whether the programs have been successfully implemented and are improving care. Furthermore, VA should take steps to improve coordination of care among PACTs, SCANs, and WRIISCs so that veterans can transition smoothly across these programs.

Dissemination of Information

Many opportunities exist for VA to disseminate information about CMI to clinicians. A major determinant of VA's ability to manage veterans who have CMI is the training of clinicians and teams of professionals in providing care for these patients.

Recommendation 8-8. The Department of Veterans Affairs (VA) should provide resources for and designate “chronic multisymptom illness champions” at each VA medical center. The champions should be integrated into the care system (for example, the patient-aligned care teams) to ensure clear communication and coordination among clinicians.

The champions should be incentivized (for example, by professional advancement and recognition and value-based payment), be given adequate time for office visits with patients who have CMI, have knowledge about the array of therapeutic options that might be useful for treating CMI, have ready access to a team of other clinicians for consultation, and have training in communication skills. Smaller VA facilities, such as community-based outreach clinics, can benefit from CMI champions. For example, the SCAN-ECHO model can be used so that clinicians in community-based outreach clinics or even civilian community-based clinics can contact a CMI champion for expert consultation.

In addition to using CMI champions to train clinicians about CMI, learning networks have been found to be effective tools for disseminating information. Continuous exchange of information among learning networks can lead to improved quality of care. The networks offer a supportive environment for learning skills informally, role models, and a benchmark for an appropriate environment for adopting new practice guidelines.

Recommendation 8-9. The Department of Veterans Affairs (VA) should develop learning, or peer, networks to introduce new information, norms, and skills related to managing veterans who have chronic multisymptom illness. Because many veterans receive care outside the VA health care system, clinicians in private practice should be offered the opportunity to be included in the learning networks and VA should have a specific focus on community outreach.

Effective patient–clinician communication and coordination of care are crucial for managing veterans who have CMI and are the foundation of patient-centered care and decision making. They are essential for managing such patients successfully.

Recommendation 8-10. The Department of Veterans Affairs should provide required education and training for its clinicians in communicating effectively with and coordinating the care of veterans who have unexplained conditions, such as chronic multisymptom illness.

Improving Data Collection and Quality

As the committee conducted its assessment of treatments for CMI and of how this condition is managed in the VA health care system, it identified gaps in data on performance measurement. To assist VA in improving outcomes and ultimately to improve the quality of care that the VA health care system provides, the committee offers the following recommendation.

Recommendation 8-11. The Department of Veterans Affairs (VA) should provide the resources needed to expand its data collection efforts to include a national system for the robust capture, aggregation, and analysis of data on the structures, processes, and outcomes of care delivery and on the satisfaction with care among patients who have chronic multisymptom illness so that gaps in clinical care can be evaluated, strategies for improvement can be planned, long-term outcomes of treatment can be assessed, and this information can be disseminated to VA health care facilities.

Research Recommendations

The committee's research recommendations are in two categories: treatments for CMI and research needs related to program evaluation.

Treatments for Chronic Multisymptom Illness. Many of the studies of treatments for CMI reviewed by the committee had methodologic flaws that limited their usefulness for the committee's evaluation.

Recommendation 8-12. Future studies funded and conducted by the Department of Veterans Affairs to assess treatments for chronic multisymptom illness should adhere to the methodologic and reporting guidelines for clinical trials, including appropriate elements (problem– patient–population, intervention, comparison, and outcome of interest) to frame the research question, extended follow-up, active comparators (such as standard of care therapies), and consistent, standardized, validated instruments for measuring outcomes.

Examples of methodologic and reporting guidelines include those set forth by such organizations as the Agency for Healthcare Research and Quality and the Institute of Medicine and in such other efforts as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Consolidated Standards of Reporting Trials statement.

On the basis of its assessment of the evidence on treatments for CMI, the committee found that several treatments and treatment approaches may be potentially useful for CMI. However, evidence sufficient to support a conclusion on their effectiveness is lacking.

Recommendation 8-13. The Department of Veterans Affairs should fund and conduct studies of interventions that evidence suggests may hold promise for treatment of chronic multisymptom illness. Specific interventions could include biofeedback, acupuncture, St. John's wort, aerobic exercise, motivational interviewing, and multimodal therapies.

Program Evaluation. As noted above, the committee did not find comprehensive evaluations of VA programs, such as the PACTs, SCAN-ECHO programs, and WRIISCs. Program evaluation—including assessments of structures, processes, and outcomes—is essential if VA is to continually improve its services and research.

Recommendation 8-14. The Department of Veterans Affairs (VA) should apply principles of quality and performance improvement to internally evaluate VA programs and research related to treatments for chronic multisymptom illness (CMI) and overall management of veterans who have CMI. This task can be accomplished using such methods as comparative effectiveness research, translational research, implementation science methods, and health systems research.