August 12, 2022

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DOD Health Care: DOD Should Monitor Implementation of Its Clinical Practice Guidelines

3 min read
<div>As of October 2020, the Departments of Defense (DOD) and Veterans Affairs (VA) had jointly developed 22 clinical practice guidelines (VA/DOD CPG) that address specific health conditions, including those related to chronic diseases, mental health issues, pain management, and rehabilitation. Such guidelines are important as military and veteran populations may have different health care needs than civilians due to involvement in combat or occupational exposures (e.g., fumes from burn pits) that may amplify physical and psychological stresses. GAO found that DOD and VA considered the health care needs of these populations throughout the guideline development process and that the guidelines include information about these health care needs in different sections. In some cases, the guidelines include treatment recommendations that specifically address the health care needs of the military and veteran populations. In other instances, they may include information about the prevalence of a specific condition for these populations, among other information. Each of the military services (Army, Air Force, and Navy) has its own process for distributing VA/DOD CPGs to providers at their military treatment facilities (MTF). However, DOD's Defense Health Agency (DHA) is in the process of assuming administrative operations—to include distributing guidelines—for all of the military services' MTFs through an incremental transition process that is to be completed by the end of September 2021. While DHA officials acknowledged that they need to develop a uniform distribution process for the guidelines once they complete the transition, MTF providers can currently access the guidelines through VA's designated website and DOD's electronic health record systems. Congress directed DOD to implement VA/DOD CPGs, using means such as providing education and training, and to monitor MTFs' implementation of them. However, GAO found that DHA and the military services are not systematically monitoring MTFs' implementation of these guidelines. While the Army tracks VA/DOD CPG education and training at its MTFs, officials with DHA, the Navy, and the Air Force explained that they have not been monitoring MTF implementation of these guidelines. DHA officials acknowledged that they need to develop a monitoring process as they assume administrative and oversight responsibilities for the military services' MTFs, but have not yet developed a plan to do so. Without a systematic process to monitor MTF implementation of these guidelines, DHA does not know the extent to which MTF providers may be using VA/DOD CPGs to reduce the variability and improve the quality of health care services provided—factors that may contribute to better health outcomes across the military health system. Through DOD's TRICARE program, eligible beneficiaries may receive care from providers at MTFs or from civilian providers. The National Defense Authorization Act for Fiscal Year 2017 required DOD to establish a program to develop, implement, update, and monitor clinical practice guidelines, which are evidence-based treatment recommendations to improve the consistency and quality of care delivered by MTF providers. The Act also included a provision for GAO to assess issues related to the military health system, including the process of ensuring that providers adhere to clinical practice guidelines, and to report annually for 4 years. This is GAO's fourth report based on the Act. This report describes (1) how the process for developing the guidelines considers the health care needs of the military and veteran populations, (2) how they are distributed by the military services to their providers and how providers access them, and (3) the extent to which DHA and the military services monitor MTF implementation of them, among other things. GAO reviewed relevant policies and guidance; analyzed each of the 22 CPGs; and interviewed officials with DOD, the military services, and VA. GAO recommends that DHA work with the military services to develop and implement a systematic process to monitor MTFs' implementation of VA/DOD CPGs. DOD concurred with this recommendation. For more information, contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov.</div>

What GAO Found

As of October 2020, the Departments of Defense (DOD) and Veterans Affairs (VA) had jointly developed 22 clinical practice guidelines (VA/DOD CPG) that address specific health conditions, including those related to chronic diseases, mental health issues, pain management, and rehabilitation. Such guidelines are important as military and veteran populations may have different health care needs than civilians due to involvement in combat or occupational exposures (e.g., fumes from burn pits) that may amplify physical and psychological stresses. GAO found that DOD and VA considered the health care needs of these populations throughout the guideline development process and that the guidelines include information about these health care needs in different sections. In some cases, the guidelines include treatment recommendations that specifically address the health care needs of the military and veteran populations. In other instances, they may include information about the prevalence of a specific condition for these populations, among other information.

Each of the military services (Army, Air Force, and Navy) has its own process for distributing VA/DOD CPGs to providers at their military treatment facilities (MTF). However, DOD’s Defense Health Agency (DHA) is in the process of assuming administrative operations—to include distributing guidelines—for all of the military services’ MTFs through an incremental transition process that is to be completed by the end of September 2021. While DHA officials acknowledged that they need to develop a uniform distribution process for the guidelines once they complete the transition, MTF providers can currently access the guidelines through VA’s designated website and DOD’s electronic health record systems.

Congress directed DOD to implement VA/DOD CPGs, using means such as providing education and training, and to monitor MTFs’ implementation of them. However, GAO found that DHA and the military services are not systematically monitoring MTFs’ implementation of these guidelines. While the Army tracks VA/DOD CPG education and training at its MTFs, officials with DHA, the Navy, and the Air Force explained that they have not been monitoring MTF implementation of these guidelines. DHA officials acknowledged that they need to develop a monitoring process as they assume administrative and oversight responsibilities for the military services’ MTFs, but have not yet developed a plan to do so. Without a systematic process to monitor MTF implementation of these guidelines, DHA does not know the extent to which MTF providers may be using VA/DOD CPGs to reduce the variability and improve the quality of health care services provided—factors that may contribute to better health outcomes across the military health system.

Why GAO Did This Study

Through DOD’s TRICARE program, eligible beneficiaries may receive care from providers at MTFs or from civilian providers. The National Defense Authorization Act for Fiscal Year 2017 required DOD to establish a program to develop, implement, update, and monitor clinical practice guidelines, which are evidence-based treatment recommendations to improve the consistency and quality of care delivered by MTF providers.

The Act also included a provision for GAO to assess issues related to the military health system, including the process of ensuring that providers adhere to clinical practice guidelines, and to report annually for 4 years. This is GAO’s fourth report based on the Act. This report describes (1) how the process for developing the guidelines considers the health care needs of the military and veteran populations, (2) how they are distributed by the military services to their providers and how providers access them, and (3) the extent to which DHA and the military services monitor MTF implementation of them, among other things. GAO reviewed relevant policies and guidance; analyzed each of the 22 CPGs; and interviewed officials with DOD, the military services, and VA.

What GAO Recommends

GAO recommends that DHA work with the military services to develop and implement a systematic process to monitor MTFs’ implementation of VA/DOD CPGs. DOD concurred with this recommendation.

For more information, contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov.

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