Gulf War Veterans (GWVs) with Chronic Multi-Symptom Illness (CMI) are twice as likely to be dissatisfied with Veterans Health Administration (VHA) care as Veterans without CMI. This suggests the need to identify the critical components of effective patient-centered care for these Veterans. The challenges of treating CMI likely center on the fact that there is continuing debate about the cause(s) of CMI. Disagreement, or non-concordance, between patients' and providers' understanding of illness (illness perceptions) are related to dissatisfaction with care n other populations. Beyond satisfaction with care, illness perceptions are thought to be the key determinant of outcomes for patients with CMI. Illness perceptions account for 33% of the variability in disability for GWVs with CMI. What is not known is how providers should address illness perceptions. Treatments that have sought to change GWVs with CMI maladaptive illness perceptions have generally suffered from poor adherence or low efficacy. An innovative approach is to assume patients are experts of their experience and providers are medical experts and that both are needed to improve care. Thus providers need to work with patients to develop individualized aligned illness perceptions. Among patients with other chronic illnesses (e.g., diabetes), patients who have concordant illness perceptions with their providers are more satisfied and have better health outcomes. This is because when patients and providers understand the illness in the same way together they create effective treatment plans to which patients want to adhere. The War Related Illness and Injury Study Center (WRIISC) is a specialized clinic for deployed Veterans with CMI. WRIISC providers seek to collaborate with a patient to align illness perceptions. Over 97% of Veterans seen at the WRIISC are satisfied with their care, yet it is not known if this satisfaction is due to concordant illness perceptions or ifthis satisfaction may ultimately improve adherence to recommendations for future utilization and self-management, and lower disability. If concordant illness perceptions were found to improve health outcomes for GWVs with CMI, this approach could be disseminated to VHA providers through existing collaborations between WRIISC and environmental health and post- deployment integrated care initiative clinical champions at each facility, to improve care for all GWVs with CMI. This application proposes an observational prospective study to examine the relationship between degree of concordance in illness perceptions between GWVs with CMI and providers and health outcomes. Clinical encounters of 100 GWVs with CMI seen at the WRIISCs, and 100 GWVs with CMI seen by a VHA Primary Care Physician will be audio recorded. Patients' perceived concordance of illness perceptions will be measured with an observer rating system and by using the Illness Concordance Questionnaire. Health outcomes will be measured one week, three months and one year after the encounter. Qualitative interviews will be conducted with 30 of the GWVs with CMI.
The aims are to determine the relationship between degree of concordance in illness perceptions between GWVs with CMI and providers and improvements in outcomes over time.
The second aim i s to compare the extent of illness perception elicitation and various outcomes at WRIISCs and usual VA primary care. Finally, identify the communication strategies providers used to elicit GWVs' illness perceptions and generate concordance in illness perceptions.

Public Health Relevance

There are almost 700,000 Persian Gulf War Veterans (GWV), with an estimated 25-30% suffering from a devastating multi-symptom illness coined Gulf War Illness or Chronic Multisymptom Illness (CMI). To address CMI, the Veterans Health Administration developed the War Related Illness and Injury Study Centers (WRIISC). The WRIISCs are specialty referral centers and provide comprehensive multidisciplinary clinical assessments for Veterans with CMI referred by their providers. GWVs with CMI are very satisfied with the care they receive at the WRIISCs (97% satisfaction). What is not known are the reasons for this satisfaction or if this satisfaction leads to improved health outcomes. The Institute of Medicine and this solicitation call for an evaluation of the WRIISC. This proposal seeks to determine the effective components of WRIISC care. While it is impractical to duplicate the WRIISCs throughout the VA, determining effective components of WRIISC care would allow for the adaptation of effective components for implementation in other VA clinics.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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HSR 8 - Service Directed Research (HSR8)
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VA New Jersey Health Care System
East Orange
United States
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