Study Suggests Quality of VA's PTSD Disability Assessment Would Improve by Using Evidence-Based Assessment
BACKGROUND:
PTSD has been the fastest growing compensated condition for both Social Security and VA. Almost 400,000 Veterans received compensation for PTSD during 2010, a 22% increase from 1999. The rapidly rising costs of PTSD 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. This multicenter, cluster-randomized trial compared usual disability examiner practices with a standardized assessment that incorporates evidence-based assessments. Using VA data, investigators identified 33 clinical examiners and 384 Veterans at six VAMCs. Veterans included in this study were those who had submitted a claim for PTSD disability and were referred to the medical center by the Veterans Benefits Administration for an initial PTSD disability assessment. Veterans were assigned to clinicians for an assessment based on the next available appointment by schedulers blind to the group assignment of the clinical examiner. Clinical examiners in the non-standardized disability assessment group continued to use their usual practice for clinical interviews; the use of adjunct psychological testing was permitted but not required. Examiners in the standardized disability group integrated the Clinician-Administered PTSD Scale to diagnose PTSD, as well as the World Health Organization Disability Assessment Schedule II to assess any functional impairment. Study outcome measures were the completeness and accuracy of the clinical interview, as assessed by expert reviewers at the VA National Center for PTSD who listened to digital recordings of the interviews.
FINDINGS:
- Administering a standardized disability assessment resulted in more complete diagnostic information on functional impairment and PTSD symptoms. Standardized assessments were 85% complete for diagnosis compared to 30% for non-standardized assessments; and for functional impairment, the rates were 76% compared to 3%.
- Standardized assessment elicited an increase in relevant information and nearly eliminated variation between examiners and medical centers.
- While the standardized examination was more sensitive than routine examination, it did not result in a significant change in the overall prevalence of diagnosed PTSD.
LIMITATIONS:
- Sources of information external to the clinical interview, i.e., psychological testing or charts, were not available to expert reviewers who measured the completeness and accuracy of clinical interviews.
- Veterans in this study did not undergo a concurrent, independent evaluation for PTSD assessment.
AUTHOR/FUNDING INFORMATION:
This study was funded by VA/HSR&D's Quality Enhancement Research Initiative (QUERI, SDR 06-331). Dr. Speroff is part of the VA Tennessee Valley Healthcare System, GRECC and Health Services Research. Dr. Sinnott is part of HSR&D's Health Economics Resource Center, Palo Alto; Dr. Marx is with the National Center for PTSD, Boston; and Dr. Owen is Director of HSR&D's Center for Mental Healthcare and Outcomes Research, North Little Rock.
Speroff T, Sinnott P, Marx B, Owen R, et al. Impact of Evidence-Based Standardized Assessment on the Disability Clinical Interview for Diagnosis of Service-Connected Post-Traumatic Stress Disorder: A Cluster Randomized Trial. Journal of Traumatic Stress 2012 December;25(6):607-15.
