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SDR 06-331 – QUERI Project

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SDR 06-331
Enhancing Equitable and Effective PTSD Disability Assessment
Theodore Speroff PhD
Tennessee Valley Healthcare System Nashville Campus, Nashville, TN
Nashville, TN
Funding Period: October 2006 - September 2011

BACKGROUND/RATIONALE:
Solicitation/Targeted Area: Many patients with PTSD have persistent impairment in work or school performance, marital and family functioning, interpersonal relationships, and social and community activities. Subsequently, patients often seek compensation from Social Security, workers compensation, and the Department of Veterans Affairs (VA). PTSD has been among the fastest growing compensated conditions for both Social Security and VA. In the United States, VA's disability compensation program is second only to Social Security Disability Insurance in size and currently covers almost 3 million Veterans. Benefit payments for service-connected PTSD from 1999 to 2004 have increased 149% (up to over $4 billion annually), whereas compensation for all other service related disabilities has increased by only 42%. The number of Veterans receiving compensation for PTSD during 2010 was 386,882, a 222% increase from 1999. This rapidly rising cost of compensation prompted a government investigation that found wide regional variations in the rates of service-connected PTSD and attributed this variance in part to variation in the diagnostic examination.

A compensation claim for injury sustained during service by the Veteran results in a request for a comprehensive examination by a skilled clinician. The work order for PTSD disability specifies the need for a DSM-IV diagnosis supported by the findings on the examination and requires the examiner to describe changes in psychosocial functional status and quality of life. It is incumbent upon the examiner to administer a complete clinical interview and provide a thorough disability report. Common practice for disability examination in the VA has been an unstructured clinical interview. Prior studies, however, suggest that unstructured clinical interviews may lack thoroughness, produce insufficient data collection, and result in incorrect application of diagnostic criteria. Within the context of disability examinations, misdiagnosis of PTSD and misspecification of functional status may lead to errors in rating decisions and inequity in distribution of compensation for disability. One approach for reducing variation and diagnostic error in clinical practice is standardization using evidence-based assessment.

VHA & VBA requested investigation on "Evidence-based Assessment of PTSD". In particular, we were requested to study two psychometric tools:
1. Clinician Assessment of PTSD Scale (CAPS)
2. World Health Organization Disability Assessment Schedule II (WHODAS-II)


OBJECTIVE(S):
Our objectives were to compare the process and outcomes of C&P exams for Initial PTSD conducted with CAPS and WHODAS-II interviews (Standardized Assessment Group) versus the current practice of PTSD exams conducted without the CAPS and WHODAS-II interviews (non-Standardized Assessment Group).

Study Questions
1. What is the effect of the CAPS/WHODAS Standardized Assessment methods on the quality of the C&P interview and on consistency of the PTSD exam?
2. What is the impact on examination cost?
3. Is it feasible to incorporate the CAPS and WHODAS into the PTSD exam?

The ultimate aim is to improve the reproducibility, consistency and validity of the PTSD examination process while maintaining a level of efficiency and cost restraint that provides veterans with an exam process that is fair, accurate and equitable across VHA.

METHODS:
This project will conduct a randomized controlled trial on 688 veterans to evaluate the effects of the CAPS/WHODAS instruments on the initial PTSD C&P examination process. Study outcomes include variation in assessing the DSM-IV components of PTSD, diagnostic accuracy, veteran perception of the exam process, VBA rater utility and resource utilization.

This study was a cluster, randomized controlled trial using qualitative and quantitative methods conducted at 6 VA medical centers. Randomization was at the level of the clinician. The two study arms were standardized, evidence based assessment using the CAPS and WHODAS instruments and the nonstandardized assessment based on the usual, routine clinical interview. The study was conducted within the real-world setting of disability examination in which exams are completed within the 30-day performance measure for timeliness. The reference standard was National Center for PTSD experts who listened to audio recordings of the disability examination. The experts scored the completeness of the assessment and provided the reference standard for functional impairment and PTSD diagnosis. Examiners logged the time spent on the various activities comprising the examination. VBA STAR reviewers conducted an audit of the adequacy of the disability examination report. Participating clinical examiners were interviewed following the study for their input and opinion about C&P examinations.

Recruitment was between March 17, 2009 and September 29, 2010. 999 veterans were eligible. We obtained written informed consent for 406 of 999 veterans (41%) and obtained data from 384 (95%). Veterans were 57% Vietnam and 23% OEF/OIF, 67% Army and 15% Marine.

FINDINGS/RESULTS:
Administering a standardized instrument (CAPS) as part of the clinical diagnostic interview for PTSD reduced variability, increased relevant information, and increased accuracy of the final diagnosis (using an expert panel listening to a taped recording of the interview as "gold standard"). The standardized exam reduced false negative diagnoses (i.e. it was more sensitive than routine examination) but did not result in a significant change in the overall prevalence of PTSD. The exam was estimated to add 15-20 minutes to the assessment process but interviews with clinicians found a majority found it useful and would support making it a routine part of the assessment (56% support/25% oppose/19% ambivalent).

Administering a standardized instrument to detect functional impairment (WHODAS) increased the likelihood that sufficient information was collected to determine level of disability (based on expert review). Administering the standardized instrument did not significantly enhance the concordance of the examiners GAF with the patient's self-report of functional impairment. However, the WHODAS scoring was more predictive of the Veterans' self-assessment than was the examiners GAF scoring. The exam was estimated to add 15-20 minutes to assessment but the vast majority of clinicians did not find it useful and would oppose making it a routine requirement. Primary objection was that it was not specific enough for disability attributable to PTSD vs. that related to other chronic conditions the Veteran might have.

Economic evaluation estimated the budget impact of adding both instruments would be to add 42 minutes to the exam at an average cost of $45, but there was wide variability by site and by individual examiner in how long routine exams took and how much longer the standardized exams take. Two of six sites were able to perform them in approximately the same time as the regular exams.

IMPACT:
This project will provide C&P examiners with evidence and guidelines for the best practice conduct of PTSD examinations and the tools for quality improvement within their organization. Congress and the public are feeling a deep responsibility to those who have suffered not only bodily but also mental injury while they have borne the battle in our recent and past military operations. This project helps the VA in being responsive to the public's concern by promoting accurate diagnosis of PTSD, fair compensation, and access to care.

We conducted two meetings with the VA central office to debrief them on the findings of this study; these meetings demonstrated how VA research can partner with operations to address problems and policy. The C&P examination and rating process is a complex process that receives ongoing discussion regarding policy for effectiveness and efficiency. We are hopeful that the knowledge gained from this study has provided input into those thoughtful discussions. By providing debriefings to the Central Office, we anticipate that the VA will be prepared for a policy response when our studies are published and disseminated within the public domain.

PUBLICATIONS:

Journal Articles

  1. Rosen MI, Afshartous D, Marx BP. Did microinsults and microaggressions play a role?: in reply. Psychiatric services (Washington, D.C.). 2013 Jul 1; 64(7):713.
  2. Rosen MI, Afshartous DR, Nwosu S, Scott MC, Jackson JC, Marx BP, Murdoch M, Sinnott PL, Speroff T. Racial differences in veterans' satisfaction with examination of disability from posttraumatic stress disorder. Psychiatric services (Washington, D.C.). 2013 Apr 1; 64(4):354-9.
  3. Speroff T, Sinnott PL, Marx B, Owen RR, Jackson JC, Greevy R, Sayer N, Murdoch M, Shane AC, Smith J, Alvarez J, Nwosu SK, Keane T, Weathers F, Schnurr PP, Friedman MJ. Impact of evidence-based standardized assessment on the disability clinical interview for diagnosis of service-connected PTSD: a cluster-randomized trial. Journal of traumatic stress. 2012 Dec 1; 25(6):607-15.
  4. Jackson JC, Sinnott PL, Marx BP, Murdoch M, Sayer NA, Alvarez JM, Greevy RA, Schnurr PP, Friedman MJ, Shane AC, Owen RR, Keane TM, Speroff T. Variation in practices and attitudes of clinicians assessing PTSD-related disability among veterans. Journal of traumatic stress. 2011 Oct 1; 24(5):609-13.
  5. Marx BP, Marshall PJ, Castro F. The moderating effects of stimulus valence and arousal on memory suppression. Emotion (Washington, D.C.). 2008 Apr 1; 8(2):199-207.
  6. Sloan DM, Marx BP, Epstein EM, Dobbs JL. Expressive writing buffers against maladaptive rumination. Emotion (Washington, D.C.). 2008 Apr 1; 8(2):302-6.
Journal Other

  1. Marx BP, Jackson JC, Schnuff PP, Murdoch M, Sayer NA, Keane TM, Friedman MJ, Greevy RA, Owen RR, Sinnott PL, Speroff T. The reality of malingered PTSD among Veterans: Reply to McNally and Frueh. Journal of traumatic stress. 2012 Aug 1; 25(4):457-60.
Conference Presentations

  1. Marx BP, Speroff T, Owen RR, Jackson JC, Greevy R, Rosen MI, Murdoch M, Sayer N, Shane A, Sinnott PA. Effectiveness of Standardized Disability Assessment for Service-Connected Posttraumatic Stress Disorder. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD.
  2. Speroff T, Sinnott P, Marx BP, Owen RR, Jackson JC, Greevy R, Murdoch M, Sayer N, Shane A, Schnurr P. A Cluster Randomized Controlled Trial on Standardized Disability Assessment for Service-Connected Post-Traumatic Stress Disorder. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD.
  3. Jackson J, Sinnot P, Marx B, Murdoch M, Alvarez J, Greevy R, Schnurr P, Sayer NA. Variation in Practices and Attitudes of Clinicians Assessing PTSD Disability. Poster session presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 1; Little Rock, AR.
  4. Feinstein BAF, Humphreys KLH, Marx BPM. Heterogeneity of Peritraumatic Responses and Posttraumatic Stress among Rape Survivors. Poster session presented at: Association for Psychological Science Annual Convention; 2008 May 1; Chicago, IL.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Epidemiology, Diagnosis
Keywords: PTSD, QUERI Implementation
MeSH Terms: none

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