VA studies: PTSD care inconsistent

The VA Medical Center in Lexington, Ky., failed to meet four out of six quality standards, making it the worst in the nation.
The VA Medical Center in Lexington, Ky., failed to meet four out of six quality standards, making it the worst in the nation. Mark Cornelison / Lexington Herald-Leader

WASHINGTON — The Department of Veterans Affairs, which touts its special programs to treat post-traumatic stress disorder in returning soldiers, spends little on those programs in some parts of the country, and some of its efforts fail to meet some of the VA's own goals, according to internal reports obtained by McClatchy Newspapers.

In fiscal year 2006, the reports show, some of the VA's specialized PTSD units spent a fraction of what the average unit did. Five medical centers — in California, Iowa, Louisiana, Tennessee and Wisconsin — spent about $100,000 on their PTSD clinical teams, less than one-fifth the national average.

The documents also show that while the VA's treatment for PTSD is generally effective, nearly a third of the agency's inpatient and other intensive PTSD units failed to meet at least one of the quality goals monitored by a VA health-research organization. The VA medical center in Lexington, Ky., failed to meet four of six quality goals, according to the internal reports.

A top VA mental-health official dismissed the reports' significance, saying veterans receive adequate care, either in specialized PTSD units or from general mental-health providers. In addition, he said, some of the spending differences aren't as extreme as the documents indicate, and the department is working to increase its resources for mental health treatment.

As the VA prepares for a surge of Iraq and Afghanistan veterans experiencing PTSD, it's come under fire for staffing and funding shortfalls in its mental health units and for the wide differences in how much it spends on such treatment at its medical centers.

The agency maintains that it delivers consistently high-quality treatment. "The best measurement of success, and what really counts, is how well we are doing in improving our patients' health," the agency's top medical official, Michael Kussman, said in a statement to McClatchy Newspapers earlier this year. "When we make comparisons among our facilities, our results are uniformly positive."

The spending and quality numbers are in two reports that a VA mental health-research office produces each year. The reports used to be readily available to the public, but the VA removed them from its Web site in the past year. McClatchy obtained the most recent reports, for fiscal year 2006, under provisions of the Freedom of Information Act.

One of the reports indicates that the number of veterans using the VA's specialized outpatient PTSD services is growing much faster than the number of medical appointments the VA is providing. The report shows that the number of veterans treated grew more than 4 percent from 2005 to 2006, while the number of appointments the VA provided grew just 1 percent, meaning that the average number of visits each veteran got dropped.

The report also says that the data "suggest considerable variability" across the VA in the delivery of some PTSD services.

"It is the task of thoughtful planning, performance assessment and clinical care to assure that, as VA passes through a period of major change during the years to come, the treatment provided to veterans with PTSD is equitably distributed, accessible, effective and efficient," the report concludes.

Paul Sullivan, a former VA official who works for the advocacy group Veterans for Common Sense, said the numbers indicated that the VA wasn't prepared to treat the number of soldiers who were coming home with PTSD.

"If the ominous trend continues or if all our Iraq soldiers return home quickly, VA's crisis may deteriorate into a full-blown catastrophe," he said.

The VA already is contending with the influx of troops from Iraq and Afghanistan as well as Vietnam-era and other veterans battling the ailment.

The agency provides mental health treatment at inpatient hospital wards and outpatient clinics. Care also is divided between general treatment and specialized programs for conditions such as PTSD.

The specialized programs are staffed by experts who concentrate on PTSD, and they've "long been recognized as an essential feature in treatment of military-related PTSD," one of the reports concludes.

"The availability of specialized PTSD programs is an important indicator of the quality of health care provided by VA," it says.

The most prevalent type of specialized program is an outpatient unit called a PTSD clinical team, and members of Congress and VA experts have pushed the agency to establish such a team at every VA medical center.

The VA has 153 medical centers, and one of the reports lists 103 centers with the special PTSD clinical units as of the end of fiscal 2006. The VA has added such units rapidly in the past year, and by the end of this year about 120 centers will have them, according to a May statement by the department.

Spending varies widely among the units, however, from more than $2,000 per treated veteran in centers in The Bronx, N.Y., and Boise, Idaho, to about $300 per treated veteran in Augusta, Ga., and about $200 in Palo Alto, Calif., one of the reports says.

Ira Katz, a top VA mental-health official, said different medical centers used different accounting systems but that the VA was working to make its PTSD care more uniform across the country.

"We want to increase the expectation of what kind of care every veteran can expect, no matter where they are," Katz said.

VA leaders are to meet this fall to help standardize the agency's PTSD program offerings. Over time, Katz said, spending on the programs will increase and the range among different centers will narrow.

Gauging the effectiveness of PTSD treatment is an inexact science, but one of the reports attempts to do so.

For treatment in hospital inpatient and other similar units, VA researchers track veterans' PTSD symptoms as well as their abuse of drugs or alcohol, propensity for violence and work habits.

They then adjust the results to account for the differences in the veterans being treated at each VA center, such as the severity of the veteran's mental illness.

Overall, the results show, treatment is effective: PTSD symptoms are reduced, for example. But some programs were better than others.

Only about 40 of the 153 VA medical centers had the specialized inpatient units, and not all of them had enough data to analyze. But 11 of the 36 that did, including the Lexington center, failed to meet at least one of the treatment goals the report tracked.

The VA researchers also came up with what they said was an overall measure of quality similar to a "cumulative grade-point average."

Lexington got the lowest marks; the VA center in Coatesville, Pa., was first. Katz said the Lexington medical center already had started to receive funding to support 20 new mental-health workers in an attempt to boost its outreach, education and treatment.

In a series of e-mails, however, he dismissed the reports' significance, saying they were produced by an internal VA research unit that's outside the agency's "formal quality improvement process."

Although the unit has been refining and publishing financial figures for several years, Katz said, the financial figures for individual PTSD programs aren't "meaningful" because of the VA centers' differing accounting procedures.

As for the services being provided, Katz said that veterans who weren't being cared for by the VA's specialized programs received "comparable care" from the system's general mental-health units. Finally, he said, the differences in outcomes among the units are minor.

"VA is always looking for ways to improve the care it provides," he said. "The apparent differences in spending and outcomes are possible signals, not scandals."

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