An evaluation of the current pre and post deployment health surveillance programs of the United States Navy and Marine Corps Essay

An evaluation of the current pre and post deployment health surveillance programs of the United States Navy and Marine Corps

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Overall compliance with DOD’s force health protection and surveillance policies for service members that deployed in support of OIF varied by service, installation, and policy requirement. Such policies require that service members be assessed before and after deploying overseas and receive certain immunizations, and that health-related documentation be maintained in a centralized location. GAO reviewed 1,862 active duty and selected reserve component service members’ medical records from a universe of 4,316 at selected military service installations participating in OIF. Overall, Army and Air Force compliance for sampled service members for OIF appears much better compared to OEF and OJG. For example:

• Lower percentages of Army and Air Force service members were missing pre- and post-deployment health assessments for OIF.

• Higher percentages of Army and Air Force service members received required pre-deployment immunizations for OIF.

• Lower percentages of deployment health-related documentation were missing in service members’ permanent medical records and at DOD’s centralized database for OIF.

The Marine Corps installations examined generally had lower levels of compliance than the other services; however, GAO did not review medical records from the Marines or Navy for OEF and OJG. Noncompliance with the requirements for health assessments may result in deployment of service members with existing health problems or concerns that are unaddressed. It may also delay appropriate medical follow-up for a health problem or concern that may have arisen during or after deployment.

            In January 2004, DOD established an overall deployment quality assurance program for ensuring that the services comply with force health protection and surveillance policies, and implementation of the program is ongoing. DOD’s quality assurance program requires

(1) reporting from DOD’s centralized database on each service’s submission of required pre deployment and post-deployment health assessments for deployed service members,

(2) reporting from each service regarding the results of the individual service’s deployment quality assurance program, and

(3) joint DOD and service representative reviews at selected military installations to validate the service’s deployment health quality assurance reporting. DOD officials believe that their quality assurance program has improved the services’ compliance with requirements.

However, the services are at different stages of implementing their own quality assurance programs as mandated by DOD. At the installations visited, GAO analysts observed that the Army and Air Force had centralized quality assurance processes in place that extensively involved medical personnel examining whether DOD’s force health protection and surveillance requirements were met for deploying/redeploying

Service members. In contrast, GAO analysts observed that the Marine Corps installations did not have well-defined quality assurance processes for ensuring that requirements were met for service members.

Our review disclosed that the extent of policy compliance varied in the following areas:

• Deployment health assessments. The Army and the Air Force installations were generally missing small percentages (less than 10 percent) of pre-deployment health assessments. In contrast, pre-deployment health assessments were missing for an estimated 63 percent8 of the service members at one Marine Corps installation and for about 27 percent at the other Marine Corps installation reviewed. The Navy installation in our review was missing pre-deployment health assessments for 24 percent of the service members. Post-deployment health assessments were completed for most service members (95 percent or more) in our samples, except at one of the Marine Corps installations we visited. While almost all post-deployment health assessments for the services were completed within DOD required time frames except for one Army installation, many of the pre-deployment health assessments in our samples were not. Except for service members at one of the two Marine Corps installations visited, a health care provider reviewed all but small percentages of the completed health assessments as required by DOD policy.

• Immunizations and other health requirements. Service members receiving all of the pre-deployment immunizations required for OIF, based on the documentation we reviewed, ranged from 52 percent to 98 percent at the installations visited. The percentage of service members missing two or more of the required immunizations, based on the documentation reviewed, ranged from 0 to about 11 percent at the installations visited. Service members missing current

tuberculosis screening at the time of their deployment ranged from 3 percent to 64 percent at the installations visited. Between less than 1 and 14 percent of the service members at the installations had blood samples in the repository that were older than the required limit of 1 year at the time of deployment. Many service members in our review at the two Marine Corps installations visited were missing their required post-deployment blood draw—19 percent at one installation and 13 percent at the other.

• Completeness of medical records and centralized data collection. Generally, service members’ permanent medical records at the installations we visited were missing small percentages (less than 11 percent) of pre- and post-deployment health assessments and immunizations we found at AMSA, with the exception of one Army and one Marine Corps installation in our review. We also checked whether service member in-theater health care visits were documented in the service member’s medical record at two Army and two Marine Corps installations that used manual patient sign-in logs, and found varying levels of missing documentation of the visits we reviewed. The Air Force and Navy installations used automated systems for recording in-theater health care visits, but we found that 20 of 40 visits reviewed at one location were not also documented in service members’ medical records. Moreover, the AMSA database—designed to function as the centralized collection location for deployment health-related information for all military services—was lacking documentation of many health assessments and immunizations that we found in service members’ medical records at the installations we visited. For example, for one of the Marine Corps installations in our review, AMSA was missing all of the pre-deployment health assessments, 26 percent of the post-deployment health assessments, and 44 percent of the immunizations that we found in the service members’ medical records. Although the number of installations we visited was limited and different than those in our previous review with the exception of Fort Campbell, the

Army and Air Force’s compliance with the requirements for OIF appears much better compared to the services’ compliance for the installations we reviewed for OEF and OJG. Because our previous report on compliance with requirements for OEF and OJG focused only on the Army and Air Force, we were unable to provide comparable data for the Navy and Marine Corps. To compare overall data from Army and Air Force active duty service members reviewed for OEF/OJG with OIF, we aggregated data from all records examined in these two reviews to provide some perspective and determined that:

• Lower percentages of Army and Air Force service members were missing pre- and post-deployment health assessments in OIF compared to OEF/OJF and, in some cases, the services were in full compliance. For example, Army service members at the Army installation reviewed who missing post-deployment health assessments upon return were

from OIF was 0 percent compared to an average of 29 for the installations we reviewed in OEF/OJG.

• Higher percentages of Army and Air Force service members received all of the required pre-deployment immunizations based on the documentation reviewed for OIF compared to OEF/OJG. In one notable example, 98 percent of the Air Force active duty service members received all of the required immunizations before deploying for OIF, compared with an average of 71 percent for OEF/OJG.

• Lower overall percentages of deployment health-related documentation were missing in the service members’ permanent medical records and at DOD’s centralized database for OIF compared to OEF/OJG, for both the Army and the Air Force. Also, immunizations for Army service members found in the medical record but missing from the centralized database was an average of 9 percent in OIF compared to an average of 62 percent in OEF/OJG.

In January 2004, DOD established an overall deployment quality assurance program for ensuring that the services comply with force health protection and surveillance policies, and implementation of the program is ongoing. DOD’s quality assurance program requires

 (1) reporting from DOD’s centralized database on each service’s submission of required pre-deployment and post-deployment health assessments for deployed

Service members,

 (2) reporting from each service regarding the results of the individual service’s deployment health quality assurance program, and

(3) joint DOD and service representative reviews at selected military installations to validate the service’s deployment health quality assurance reporting. DOD officials believe that their quality assurance program has improved the services’ compliance with requirements. However, the services are at different stages of implementing their own quality assurance programs as mandated by DOD.

For example, as of September 2004, the Army had conducted quality assurance reviews to assess compliance with force health protection and surveillance requirements at 10 Army installations. However, according to an official in the office of the Surgeon General of the Navy, no decisions have been reached regarding whether periodic audits of Navy service members’ medical records will be conducted to assess compliance with DOD requirements.

At the installations we visited, we observed that the Army and Air Force had centralized quality assurance processes in place that extensively involved medical personnel examining whether DOD’s force health protection and surveillance requirements were met for deploying/re-deploying service members. In contrast, we observed that the Marine Corps installations we reviewed did not have well-defined quality assurance processes for ensuring that the requirements were met for service members. We did not evaluate the effectiveness of DOD’s deployment quality assurance program because of the relatively short time of its implementation. In a September 2004 report, we made recommendations to improve the submission and timeliness of pre- and post-deployment health assessments to AMSA. Specifically, we recommended that the Secretary of Defense direct the Commandant of the Marine Corps to establish a mechanism to oversee the submission of pre- and post-deployment assessments to AMSA, and to direct the Under Secretary of Defense for Personnel and Readiness, in concert with the service secretaries, to take steps to improve the electronic submission of pre- and post-deployment health assessments. In a September 2003 report, we also recommended that DOD establish an effective quality assurance program and we continue to believe that implementation of such a program could help the Marine Corps improve its compliance with force health protection and surveillance requirements. Because of these prior recommendations and the recency of DOD’s implementation of its quality assurance program, we are not making any additional recommendations regarding the program at this time.

Service members in our review at the Army and Air Force installations were generally missing small percentages of pre-deployment health assessments. In contrast, pre-deployment health assessments were missing for an estimated 63 percent of the service  members at one Marine Corps installation and for 27 percent at the other Marine Corps installation visited. Similarly, the Navy installation we visited was missing pre-deployment health assessments for about 24 percent of the service members; however, we note that the pre-deployment health assessments reviewed for Navy service members were completed prior to June 1, 2003, and may not reflect improvements arising from increased emphasis following our prior review of the Army

and Air Force’s compliance for OEF/OJG.

            Noncompliance with the requirements for pre-deployment health assessments may result in service members with existing health problems or concerns being deployed with unaddressed health problems. Also, failure to complete post-deployment health assessments may risk a delay in obtaining appropriate medical follow-up attention for a health problem or concern that may have arisen during or following the deployment. Based on our samples, the services did not fully meet immunization and other health requirements for OIF deployments, although all service members in our sample had received at least one anthrax immunization before they returned from the deployment as required. Almost all of the service members in our samples had a pre-deployment blood sample in the DOD Serum Repository but frequently the blood sample was older than the one-year requirement. The services’ record in regard to post-deployment blood sample draws was mixed. The U.S. Central Command required the following pre-deployment

immunizations for all service members who deployed to Southwest Asia in support of OIF: hepatitis A (two-shot series); measles, mumps, and rubella; polio; tetanus/diphtheria within the last 10 years; typhoid within the last 5 years; and influenza within the last 12 months. Based on the documentation we reviewed, the estimated percent of service members receiving all of the required pre-deployment immunizations ranged from 52 percent to 98 percent at the installations we visited. The percent of service members missing only one of the pre-deployment immunizations required for the OIF deployment ranged from 2 percent to 43 percent at the installations we visited. Furthermore, the percent of service members missing 2 or more of the required immunizations ranged from 0 percent to 11 percent.

            Although not required as pre-deployment immunizations, U.S. Central Command policies require that service members deployed to Southwest Asia in support of OIF receive a smallpox immunization and at least one anthrax immunization either before deployment or while in theater. For the service members in our samples at the installations visited, we found that all of the service members received at least one anthrax immunization in accordance with the requirement. Only small percentages of service members at two of the three Army installations, the Air Force

installation, and the Navy installation visited did not receive the required smallpox immunization. However, an estimated 18 percent of the service members at Fort Lewis, 8 percent at Camp Lejeune, and 27 percent at Camp Pendleton did not receive the required smallpox immunization.

U.S. Central Command policies also require that deploying service members have a blood sample in the DOD Serum Repository not older than 12 months prior to deployment. Almost all of the service members in our review had a pre-deployment blood sample in the DOD Serum Repository, but frequently the blood samples were older than the 1-year requirement. 14 percent of service members at Camp Pendleton had blood samples in the repository older than 1 year.

            Army and Marine Corps representatives associated with the battalion aid stations we examined commented that the aid stations were frequently moving around the theater, increasing the likelihood that paper documentation of the visits might get lost and that such visits might not always be documented because of the hostile environment. The lack of complete and accurate medical records documenting all medical care for the individual service member complicates the service member’s post-deployment medical care. For example, accurate medical records are essential for the delivery of high-quality medical care and important for epidemiological analysis following deployments. According to DOD health officials, the lack of complete and accurate medical records complicated the diagnosis and treatment of service members who experienced post-deployment health problems that they attributed to their military service in the Persian Gulf in 1990-91. DOD’s Theater Medical Information Program (TMIP) has the capability to electronically record and store in-theater patient medical encounter data. However, the Iraq war has delayed implementation of the program. At the request of the services, the operational test and evaluation for TMIP has been delayed until the second quarter of fiscal year 2005.

In addition to the above requirements, Public Law 105-85, 10 U.S.C. 1074f, requires the Secretary of Defense to retain and maintain health-related records in a centralized location for service members who are deployed. This includes records for all medical examinations conducted to ascertain the medical condition of service members before deployment and any changes during their deployment, all health care services (including immunizations) received in anticipation of deployment or during the deployment, and events occurring in the deployment area that may affect the health of service members. A February 2002 Joint Staff memorandum requires the services to forward a copy of the completed pre-deployment and post-deployment health assessments to AMSA for centralized retention.

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