December 8, 2021

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Veterans Health Care: Agency Efforts to Provide and Study Prosthetics for Small but Growing Female Veteran Population

14 min read
<div>The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) provides veterans with prosthetic services to assist with their mobility, vision, and hearing needs. The proportion of prosthetics VHA provided to female veterans has been small compared to the share provided to male veterans. However, in fiscal years 2015 to 2019, this proportion grew from 6.8 percent to 7.9 percent and accounted for about $889.1 million of the $15.4 billion total cost of prosthetics. Artificial limbs comprised a relatively small number of the total prosthetics VHA provided to veterans in fiscal years 2015 to 2019; however, veterans who use artificial limbs have complex needs and are significant users of health care services. VHA provided prosthetic services to a small but growing female veteran amputee population (almost 3 percent of veteran amputees in fiscal year 2019), who were generally younger than male veteran amputees. VHA has established an individualized patient care approach in its Amputation System of Care that seeks to address the prosthetic needs of each veteran, including accounting for gender-specific factors. VHA officials said that using a standardized, multidisciplinary approach across VA medical facilities also helps them incorporate the concerns and preferences of female veterans. For example, veterans are provided care by a team that includes a physician, therapist, prosthetist (clinician who helps evaluate prosthetic needs and then designs, fabricates, fits, and adjusts artificial limbs), and other providers as needed. Female veteran amputees GAO spoke with at one VA medical facility said they were satisfied with their VHA care. They also noted a lack of commercially available prosthetic options that VHA providers can use to meet women's needs. Examples of Female Veterans' Artificial Limb Prosthetics Women are generally studied less than their male counterparts in prosthetic and amputee rehabilitation research. VHA designated prosthetics for female veterans a national research priority in 2017, and has funded eight related studies as of May 2020: four pertain to lower limb amputation, three pertain to upper limb amputation, and one pertains to wheelchairs. VHA officials noted the importance of this research priority and the ongoing challenge of recruiting study participants due to the small female veteran population. VHA researchers said they employ various tactics to address this challenge, such as using multi-site studies and recruiting participants from the non-veteran population. Women are the fastest growing veteran subpopulation, with the number of female veterans using VHA health care services increasing 29 percent from 2014 to 2019. Female veterans accounted for an estimated 10 percent of the total veteran population in fiscal year 2019. They are eligible to receive a full range of VHA health care services, including obtaining prosthetics. House Report 115-188 included a provision for GAO to review VHA's prosthetic services for female veterans. This report examines 1) trends in prosthetics provided by VHA to female veterans; 2) characteristics of the female veteran population with limb loss and how VHA provides prosthetic services to these veterans through its Amputation System of Care; and 3) VHA's research efforts and the challenges that exist in studying prosthetics for female veterans with limb loss. GAO analyzed VHA documents, as well as data from fiscal years 2015 to 2019 on prosthetics and veterans with amputations. GAO interviewed agency officials from VHA central office and officials and female veteran amputees at two VA medical facilities selected for expertise in amputation care and prosthetics research activities. In addition, GAO interviewed VHA researchers conducting studies on prosthetics for female veterans. GAO provided a draft of this report to VA. VA provided general and technical comments, which were incorporated as appropriate. For more information, contact Jessica Farb at (202) 512-7114 or farbj@gao.gov.</div>

What GAO Found

The Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA) provides veterans with prosthetic services to assist with their mobility, vision, and hearing needs. The proportion of prosthetics VHA provided to female veterans has been small compared to the share provided to male veterans. However, in fiscal years 2015 to 2019, this proportion grew from 6.8 percent to 7.9 percent and accounted for about $889.1 million of the $15.4 billion total cost of prosthetics.

Artificial limbs comprised a relatively small number of the total prosthetics VHA provided to veterans in fiscal years 2015 to 2019; however, veterans who use artificial limbs have complex needs and are significant users of health care services. VHA provided prosthetic services to a small but growing female veteran amputee population (almost 3 percent of veteran amputees in fiscal year 2019), who were generally younger than male veteran amputees.

VHA has established an individualized patient care approach in its Amputation System of Care that seeks to address the prosthetic needs of each veteran, including accounting for gender-specific factors. VHA officials said that using a standardized, multidisciplinary approach across VA medical facilities also helps them incorporate the concerns and preferences of female veterans. For example, veterans are provided care by a team that includes a physician, therapist, prosthetist (clinician who helps evaluate prosthetic needs and then designs, fabricates, fits, and adjusts artificial limbs), and other providers as needed. Female veteran amputees GAO spoke with at one VA medical facility said they were satisfied with their VHA care. They also noted a lack of commercially available prosthetic options that VHA providers can use to meet women’s needs.

Examples of Female Veterans’ Artificial Limb Prosthetics

Women are generally studied less than their male counterparts in prosthetic and amputee rehabilitation research. VHA designated prosthetics for female veterans a national research priority in 2017, and has funded eight related studies as of May 2020: four pertain to lower limb amputation, three pertain to upper limb amputation, and one pertains to wheelchairs. VHA officials noted the importance of this research priority and the ongoing challenge of recruiting study participants due to the small female veteran population. VHA researchers said they employ various tactics to address this challenge, such as using multi-site studies and recruiting participants from the non-veteran population.

Why GAO Did This Study

Women are the fastest growing veteran subpopulation, with the number of female veterans using VHA health care services increasing 29 percent from 2014 to 2019. Female veterans accounted for an estimated 10 percent of the total veteran population in fiscal year 2019. They are eligible to receive a full range of VHA health care services, including obtaining prosthetics.

House Report 115-188 included a provision for GAO to review VHA’s prosthetic services for female veterans. This report examines 1) trends in prosthetics provided by VHA to female veterans; 2) characteristics of the female veteran population with limb loss and how VHA provides prosthetic services to these veterans through its Amputation System of Care; and 3) VHA’s research efforts and the challenges that exist in studying prosthetics for female veterans with limb loss.

GAO analyzed VHA documents, as well as data from fiscal years 2015 to 2019 on prosthetics and veterans with amputations. GAO interviewed agency officials from VHA central office and officials and female veteran amputees at two VA medical facilities selected for expertise in amputation care and prosthetics research activities. In addition, GAO interviewed VHA researchers conducting studies on prosthetics for female veterans.

GAO provided a draft of this report to VA. VA provided general and technical comments, which were incorporated as appropriate.

For more information, contact Jessica Farb at (202) 512-7114 or farbj@gao.gov.

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  • Military Training: DOD Met Annual Reporting Requirements and Improved Its Sustainable Ranges Report
    In U.S GAO News
    What GAO FoundIn our view, DOD's 2012 sustainable ranges report meets the annual statutory reporting requirements that DOD describe its progress in implementing its sustainable ranges plan and any additional actions taken or to be taken in addressing training constraints caused by limitations on the use of military lands, marine areas, and airspace. DOD's 2012 report also provides updates to several elements of the plan that the act required DOD to include in its original submission in 2004. These elements include (1) proposals to enhance training range capabilities and address any shortfalls in resources, (2) goals and milestones for tracking planned actions and measuring progress, and (3) projected funding requirements for implementing planned actions, among others. Taken together, these elements of DOD's 2012 sustainable ranges report describe the department's progress in implementing its comprehensive plan and addressing training constraints at its ranges, thus meeting the annual reporting requirements of the act.DOD has taken action in response to all 13 prior GAO recommendations that focused on meeting the requirements of the act and improving the report submissions and has completed implementation of all but two of those recommendations. In response to three recommendations in our 2011 report, DOD included additional information in its goals, actions, and milestones and funding requirements sections in the 2012 sustainable ranges report. In our earlier reviews of DOD's annual sustainable ranges report, we identified a total of 10 recommendations. DOD has since completed implementation of all but two of the prior recommendations, which related to readiness reporting. DOD has been addressing these two recommendations by developing and testing a range assessment module for the Defense Readiness Reporting System (DRRS), and expects to complete its review by the end of fiscal year 2012. Through the changes DOD has implemented in its annual reporting over the past several years, many based on GAO recommendations, DOD has continued to improve its reporting on its sustainable ranges. We are making no new recommendations in this report.Why GAO Did This StudyThe Department of Defense (DOD) relies on access to military land, airspace, sea space, and frequency spectrum to provide its forces a realistic training environment that will ready them to face combat or complex missions around the globe. Over the decades, however, several factors collectively known as encroachment have increasingly challenged the military's access to these resources. Additionally, increased operational tempo and overseas deployments, specifically in support of operations in Iraq and Afghanistan, have strained the ability of some existing range resources and infrastructures to continue supporting training at the levels required by DOD and the military services. To respond to these challenges and increase the long-term sustainability of its military range resources, DOD has launched a number of efforts aimed both at preserving its training ranges and addressing the effects of its training activities on the environment and on local communities.Section 366 of the Bob Stump National Defense Authorization Act for Fiscal Year 2003 (as amended) required DOD to submit a comprehensive plan for using existing authorities available to the department to address training constraints caused by limitations on the use of military lands, marine areas, and airspace in the United States and overseas to Congress at the same time as the President submitted his budget for fiscal year 2004. Further, Section 366 required DOD to submit an annual progress report to Congress along with the President's budget for fiscal years 2005 through 2013. To address these requirements, DOD has submitted an annual sustainable ranges report since 2004. In addition, the act directed us to submit annual evaluations of DOD's reports to Congress within 90 days of receiving these reports from DOD. Our review of DOD's 2012 sustainable ranges report is our ninth annual report in response to the act. In this review, we discuss (1) the extent to which DOD's 2012 sustainable ranges report meets the statutory requirements and (2) the extent to which DOD has acted on GAO recommendations to improve its report submissions and what opportunities, if any, exist for DOD to improve future reporting.For more information, contact Brian J. Lepore at (202) 512-4523 or leporeb@gao.gov.
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  • Preliminary Observations on the Use and Oversight of U.S. Coalition Support Funds Provided to Pakistan
    In U.S GAO News
    According to U.S. embassy officials in Islamabad and unclassified U.S. intelligence documents, since 2002, al Qaeda and the Taliban have used Pakistan's Federally Administered Tribal Areas (FATA) and the border region to attack Pakistani, Afghan, U.S. and coalition troops; plan and train for attacks against U.S. interests; destabilize Pakistan; and spread radical Islamist ideologies that threaten U.S. interests. Since October 2001, the United States has provided Pakistan with over $10 billion for military, economic, and development activities in support of the critical U.S. national security goals of destroying terrorist threats and closing terrorist safe havens. A major component of this effort has been U.S. Coalition Support Funds (CSF) reimbursed to Pakistan. The purpose of CSF is to reimburse coalition countries for logistical and military support provided to United States military operations in the global war on terror. In Pakistan, reimbursements through CSF are intended to enable the government of Pakistan to attack terrorist networks in the FATA and stabilize the border areas. It is structured as a reimbursement mechanism in which the U.S. Department of Defense (Defense) policy is to validate that support was provided, costs were incurred, and these costs were incremental to normal Pakistani military operations. We were asked to assess how CSF reimbursements have been used to meet U.S. goals in Pakistan, and what controls exist to ensure that reimbursements are for legitimate claims.For the period covering October 2001 through June 2007, the United States reimbursed Pakistan about $5.56 billion in CSF for military operations in FATA and other support in the war on terror. CSF reimbursement funds are paid directly into the Pakistani government treasury and become sovereign funds. Once they become sovereign funds, the U.S. government has no oversight authority over these funds. In response to a Defense Inspector General review conducted in 2003, DOD implemented additional guidance to improve oversight of the CSF reimbursed to Pakistan. Moreover, in 2007, the Office of the Defense Representative to Pakistan (ODRP) began playing a larger role in overseeing CSF reimbursement claims. In performing oversight, ODRP reviews the Pakistani claims and indicates that to the best of their knowledge military support was provided and expenses were actually incurred. U.S. Central Command (CENTCOM) then validates that Pakistani operations listed were essential to support U.S. military operations in the theater. The claims are sent to the Office of the Under Secretary of Defense for Comptroller, who (1) performs a macro-level review comparing the cost to similar operations, and (2) assesses whether the cost categories are reasonable, selected subcategories are reasonable compared to U.S. costs, and costs are consistent with previous claims. In addition, both the Undersecretary of Defense for Policy and the State Department verify that the reimbursement is consistent with the U.S. government's National Security Strategy and that the CSF payment does not adversely impact the balance of power in the region. In recent months, Defense has disallowed or deferred a significantly greater amount of CSF reimbursement claims from Pakistan.
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  • Valley drug trafficking organizer gets life in prison
    In Justice News
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  • Food Safety: CDC Could Further Strengthen Its Efforts to Identify and Respond to Foodborne Illnesses
    In U.S GAO News
    The roles and responsibilities of the Centers for Disease Control and Prevention (CDC) during a multistate foodborne illness outbreak include analyzing federal foodborne illness surveillance networks to identify outbreaks, leading investigations to determine the food causing the outbreak, and communicating with the public. CDC also works to build and maintain federal, state, territorial, and local capacity to respond to foodborne illness outbreaks by awarding funds to state and local public health agencies and through other initiatives. In identifying and responding to multistate foodborne illness outbreaks, CDC faces challenges related to clinical methods and communication, and it has taken some steps to respond to these challenges. One challenge stems from the increasing clinical use of culture-independent diagnostic tests (CIDTs). CIDTs diagnose foodborne illnesses faster and cheaper than traditional methods, but because they do not create DNA fingerprints that can specify a pathogen, they may reduce CDC's ability to identify an outbreak. A CDC working group recommended in May 2018 that CDC develop a plan to respond to the increasing use of CIDTs. By developing a plan, CDC will have greater assurance of continued access to necessary information. CDC also faces a challenge in balancing the competing needs for timeliness and accuracy in its outbreak communications while maintaining public trust. CDC has an internal framework to guide its communications decisions during outbreaks, and it recognizes that stakeholders would like more transparency about these decisions. By making its framework publicly available, CDC could better foster public trust in its information and guidance during outbreaks. CDC has taken steps to evaluate its performance in identifying and responding to multistate outbreaks. Specifically, CDC has developed general strategic goals (see fig.) and taken initial steps to develop performance measures. However, CDC has not yet established other elements of a performance assessment system—an important component of effective program management. CDC's Use of Elements of Program Performance Assessment Systems In particular, CDC has not set specific performance goals, used performance measures to track progress, or conducted a program evaluation of its multistate foodborne illness outbreak investigation efforts. By implementing all elements of a performance assessment system, CDC could better assess its progress toward meeting its goals, identify potentially underperforming areas, and use that information to improve its performance. CDC has estimated that each year, one in six people in the United States gets a foodborne illness, 128,000 are hospitalized, and 3,000 die. CDC data show increases in the number of reported multistate foodborne illness outbreaks—groups of two or more linked cases in multiple states—in recent years. Such outbreaks are responsible for a disproportionate number of hospitalizations and deaths, compared with single-state outbreaks. GAO was asked to review CDC's response to multistate foodborne illness outbreaks. This report examines (1) CDC's roles and responsibilities, (2) challenges that CDC faces and the extent to which it has addressed these challenges, and (3) the extent to which CDC evaluates its performance. GAO reviewed agency documents and data; conducted site visits and case studies; and interviewed federal, state, and local public health officials, as well as representatives of stakeholder groups. GAO is recommending that CDC (1) develop a plan to respond to the increasing use of CIDTs, (2) make publicly available its decision-making framework for communicating about multistate foodborne illness outbreaks, and (3) implement all the elements of a performance assessment system. CDC concurred with all three recommendations. For more information, contact Steve D. Morris at (202) 512-3841 or morriss@gao.gov.
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