Another weakness of the hospitalization data systems has been the lack of coverage of outpatient medical care. DOD currently has no centralized reporting system for its outpatient facilities, although an automated system is under development. Until recently, VA did not have an automated system either. Using DOD’s and VA’s Automated Hospitalization Reporting Systems to Assess Tumors Among Gulf War Veterans

			VA Tumors Analysis

In May 1996, VA completed an analysis requested by your Subcommittee that provided some information on the number of tumors among Gulf War veterans compared with the number in a sample of nondeployed veterans. Cancer registries can be effective tools for determining incidence rates and for directing cancer control efforts. Voluntary reporting is also encouraged from DOD and VA hospitals. The study design notes that it would not be informative to analyze cancer incidence sooner because the time interval between any exposures that may have occurred during the Gulf War and the diagnosis of most cancers is “probably at least 10 years and may extend as long as 20 to 40 years.” It is also intended that these health outcomes be linked to information about potential environmental exposure factors that may exist or become available from DOD military records and other sources, including the location database being compiled by the U.S. Army Center for Health Promotion and Preventive Medicine. Gulf War Veteran Health Registries

Both DOD and VA have established separate programs that provide medical examinations and diagnostic services, free of charge, to Gulf War veterans. While the registry programs are primarily intended to provide diagnostic services and treatment to Gulf War veterans, the programs also gather and report data on the nature of the veterans’ health problems and the types of risk factors veterans may have been exposed to in the Gulf War. As designed, the registries are not intended to be used to determine the frequency and causes of illnesses among the general Gulf War veteran population. VA National Survey

This approach is being employed by VA to study the general health status of Gulf War veterans. The overall response rate to the survey has been relatively low (57 percent). The sample size of VA’s survey may also be too small to identify elevated incidence of most cancers. With respect to the issue of statistical power, VA has acknowledged that, “the study may provide inadequate statistical power to detect a small increase in risk for rare adverse health outcomes in a particular subgroup of veterans.”
In 1996, the Institute of Medicine concluded, “This is a well-designed and well-intended study.” According to the Institute, however, “there appeared to be little statistical input in the analysis plan reviewed, and these data will require sophisticated statistical adjustment.”

		Iowa State Survey

A population-based survey to assess the prevalence of self-reported symptoms and illnesses among Gulf War veterans was also conducted in Iowa. However, the existing data sources and research applications we reviewed, provide very limited information about the incidence of tumors or other illnesses among Gulf War veterans. Thus, it will also be difficult to determine whether Gulf War veterans have a higher incidence of tumors than other veterans in the future. They noted the report does a good job in highlighting the strengths and weaknesses of the data sources available for assessing the incidence of tumors among Gulf War veterans, but that it does not include a comparable review of other non-cancer health information systems or research studies that may exist.
Why GAO Did This Study

Pursuant to a congressional request, GAO reviewed data on the incidence of tumors among Gulf War veterans, focusing on: (1) the reliability of data sources available for determining the incidence of tumors among Gulf War veterans; and (2) the Department of Veterans Affairs' (VA) and the Department of Defense's (DOD) use of data sources to monitor tumors and other illnesses among Gulf War veterans.

What GAO Found

GAO noted that: (1) none of the data sources that provide information on the health characteristics of Gulf War veterans can be used to reliably estimate the incidence of tumors; (2) VA's benefits information system can track the vital status and causes of deaths among Gulf War veterans; (3) however, not all cancers result in death and those that do may take several years to show up; (4) as a result, the system will underreport overall incidence; (5) DOD and VA maintain large hospitalization reporting systems; (6) however, a large majority of Gulf War veterans do not use DOD and VA hospitals and there has been little effort to determine whether this hidden population has health conditions similar to those of the population captured by the reporting systems; (7) DOD's reporting system also does not account for outpatient medical care; (8) VA has recently begun to fill this gap for its outpatient facilities, but it may take several years before consistent and reliable reporting is available; (9) a national cancer registry reports aggregate population rates and trends but cannot be used to track the Gulf War population; (10) DOD and VA health registries report information on the type of health problems Gulf War veterans have experienced at the time of their examination; (11) however, because not all veterans are examined, the information collected cannot be used to estimate the frequency of illnesses among all Gulf War veterans; (12) VA is conducting a national survey to study the general health status of Gulf War veterans; (13) the study uses representative samples of deployed and nondeployed veterans; (14) however, the response rate to the survey has been low and the study's sample size may be too small to assess any elevated incidence of most cancers; (15) DOD and VA have initiated efforts to improve the utility of these data systems but have not developed the capability to specifically address questions about tumors or other illnesses among Gulf War veterans; (16) as a result, it is not known how many Gulf War veterans have tumors or whether they have a higher incidence of them than other veterans; and (17) according to agency officials, no other plans aside from periodic assessments of mortality have been made to monitor tumor cases within this population.