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21st Century System for Evaluating Veterans'' Disability Benefits recommends improvements in the medical evaluation and rating of veterans for the benefits provided by the Department of Veterans Affairs (VA) to compensate for illnesses or injuries incurred in or aggravated by military service. Compensation is a monthly cash benefit based on a rating schedule that determines the degree of disability on a scale of 0 to 100. Although a disability rating may also entitle a veteran to ancillary services, such as vocational rehabilitation and employment services, the rating schedule is out of date medically and contains ambiguous criteria and obsolete conditions and language. The current rating schedule emphasizes impairment and limitations or loss of specific body structures and functions which may not predict disability well. 21st Century System for Evaluating Veterans'' Disability Benefits recommends that this schedule could be revised to include modern concepts of disability including work disability, nonwork disability, and quality of life.

In addition to the need for an updated rating schedule, this book highlights the need for the Department of Veterans'' Affairs to devote additional resources to systematic analysis of how well it is providing services or how much the lives of veterans are being improved, as well as the need for a program of research oriented toward understanding and improving the effectiveness of its benefits programs.

The United States has long recognized and honored the service and sacrifices of its military and veterans. Veterans who have been injured by their service (whether their injury appears during service or afterwards) are owed appropriate health care and disability compensation. For some medical conditions that develop after military service, the scientific information needed to connect the health conditions to the circumstances of service may be incomplete. When information is incomplete, Congress or the Department of Veterans Affairs (VA) may need to make a "presumption" of service connection so that a group of veterans can be appropriately compensated.

The missing information may be about the specific exposures of the veterans, or there may be incomplete scientific evidence as to whether an exposure during service causes the health condition of concern. For example, when the exposures of military personnel in Vietnam to Agent Orange could not be clearly documented, a presumption was established that all those who set foot on Vietnam soil were exposed to Agent Orange. The Institute of Medicine (IOM) Committee was charged with reviewing and describing how presumptions have been made in the past and, if needed, to make recommendations for an improved scientific framework that could be used in the future for determining if a presumption should be made. The Committee was asked to consider and describe the processes of all participants in the current presumptive disability decision-making process for veterans. The Committee was not asked to offer an opinion about past presumptive decisions or to suggest specific future presumptions.

The Committee heard from a range of groups that figure into this decision-making process, including past and present staffers from Congress, the VA, the IOM, veterans service organizations, and individual veterans. The Department of Defense (DoD) briefed the Committee about its current activities and plans to better track the exposures and health conditions of military personnel. The Committee further documented the current process by developing case studies around exposures and health conditions for which presumptions had been made. Improving the Presumptive Disability Decision-Making Process for Veterans explains recommendations made by the committee general methods by which scientists, as well as government and other organizations, evaluate scientific evidence in order to determine if a specific exposure causes a health condition.

A fundamental challenge in past studies evaluating whether health problems experienced by Vietnam veterans might be linked to wartime use of Agent Orange or other herbicides has been a lack of information about the veterans'' level of exposure to these herbicides. To address that problem, researchers developed a model to assess the opportunity for herbicide exposure among these veterans.

The Utility of Proximity-Based Herbicide Exposure Assessment in Epidemiologic Studies of Vietnam Veterans presents the conclusions and recommendations of an Institute of Medicine committee (IOM) that was convened to provide guidance to the Department of Veterans Affairs (VA) about the best use of a model to characterize exposure to the troops based on their proximity to herbicide spraying in Vietnam. This book''s assessment is guided by four primary considerations: to be clear about what the assessment model does and does not claim to do; to gain understanding of the strengths and limitations of data on herbicide spraying, troop locations, and health outcomes; to consider whether the model locates spraying and troops accurately to consider the potential contributions and pitfalls of using it in epidemiologic studies. Of particular interest in these deliberations were the degree to which exposure classification might be improved if the model were to be used, and the appropriate interpretation of the results of any such studies.

In light of the questions that remain concerning herbicide exposure and health among Vietnam veterans and the array of evidence that has thus far been brought to bear on that issue, The Utility of Proximity-Based Herbicide Exposure Assessment in Epidemiologic Studies of Vietnam Veterans concludes that the application of this model offers a constructive approach to extending knowledge about the effects of herbicides on the health of these veterans and merits the initial steps recommended in our report.

The United States has long recognized and honored the service and sacrifices of its military and veterans. Veterans who have been injured by their service (whether their injury appears during service or afterwards) are owed appropriate health care and disability compensation. For some medical conditions that develop after military service, the scientific information needed to connect the health conditions to the circumstances of service may be incomplete. When information is incomplete, Congress or the Department of Veterans Affairs (VA) may need to make a "presumption" of service connection so that a group of veterans can be appropriately compensated.

The missing information may be about the specific exposures of the veterans, or there may be incomplete scientific evidence as to whether an exposure during service causes the health condition of concern. For example, when the exposures of military personnel in Vietnam to Agent Orange could not be clearly documented, a presumption was established that all those who set foot on Vietnam soil were exposed to Agent Orange. The Institute of Medicine (IOM) Committee was charged with reviewing and describing how presumptions have been made in the past and, if needed, to make recommendations for an improved scientific framework that could be used in the future for determining if a presumption should be made. The Committee was asked to consider and describe the processes of all participants in the current presumptive disability decision-making process for veterans. The Committee was not asked to offer an opinion about past presumptive decisions or to suggest specific future presumptions.

The Committee heard from a range of groups that figure into this decision-making process, including past and present staffers from Congress, the VA, the IOM, veterans service organizations, and individual veterans. The Department of Defense (DoD) briefed the Committee about its current activities and plans to better track the exposures and health conditions of military personnel. The Committee further documented the current process by developing case studies around exposures and health conditions for which presumptions had been made. Improving the Presumptive Disability Decision-Making Process for Veterans explains recommendations made by the committee general methods by which scientists, as well as government and other organizations, evaluate scientific evidence in order to determine if a specific exposure causes a health condition.

21st Century System for Evaluating Veterans'' Disability Benefits recommends improvements in the medical evaluation and rating of veterans for the benefits provided by the Department of Veterans Affairs (VA) to compensate for illnesses or injuries incurred in or aggravated by military service. Compensation is a monthly cash benefit based on a rating schedule that determines the degree of disability on a scale of 0 to 100. Although a disability rating may also entitle a veteran to ancillary services, such as vocational rehabilitation and employment services, the rating schedule is out of date medically and contains ambiguous criteria and obsolete conditions and language. The current rating schedule emphasizes impairment and limitations or loss of specific body structures and functions which may not predict disability well. 21st Century System for Evaluating Veterans'' Disability Benefits recommends that this schedule could be revised to include modern concepts of disability including work disability, nonwork disability, and quality of life.

In addition to the need for an updated rating schedule, this book highlights the need for the Department of Veterans'' Affairs to devote additional resources to systematic analysis of how well it is providing services or how much the lives of veterans are being improved, as well as the need for a program of research oriented toward understanding and improving the effectiveness of its benefits programs.

A fundamental challenge in past studies evaluating whether health problems experienced by Vietnam veterans might be linked to wartime use of Agent Orange or other herbicides has been a lack of information about the veterans'' level of exposure to these herbicides. To address that problem, researchers developed a model to assess the opportunity for herbicide exposure among these veterans.

The Utility of Proximity-Based Herbicide Exposure Assessment in Epidemiologic Studies of Vietnam Veterans presents the conclusions and recommendations of an Institute of Medicine committee (IOM) that was convened to provide guidance to the Department of Veterans Affairs (VA) about the best use of a model to characterize exposure to the troops based on their proximity to herbicide spraying in Vietnam. This book''s assessment is guided by four primary considerations: to be clear about what the assessment model does and does not claim to do; to gain understanding of the strengths and limitations of data on herbicide spraying, troop locations, and health outcomes; to consider whether the model locates spraying and troops accurately to consider the potential contributions and pitfalls of using it in epidemiologic studies. Of particular interest in these deliberations were the degree to which exposure classification might be improved if the model were to be used, and the appropriate interpretation of the results of any such studies.

In light of the questions that remain concerning herbicide exposure and health among Vietnam veterans and the array of evidence that has thus far been brought to bear on that issue, The Utility of Proximity-Based Herbicide Exposure Assessment in Epidemiologic Studies of Vietnam Veterans concludes that the application of this model offers a constructive approach to extending knowledge about the effects of herbicides on the health of these veterans and merits the initial steps recommended in our report.

The Social Security Administration (SSA) provides Social Security Disability Insurance (SSDI) benefits to disabled persons of less than full retirement age and to their dependents. SSA also provides Supplemental Security Income (SSI) payments to disabled persons who are under age 65. For both programs, disability is defined as a "medically determinable physical or mental impairment" that prevents an individual from engaging in any substantial gainful activity and is expected to last at least 12 months or result in death.Assuming that an applicant meets the nonmedical requirements for eligibility (e.g., quarters of covered employment for SSDI; income and asset limits for SSI), the file is sent to the Disability Determination Services (DDS) agency operated by the state in which he or she lives for a determination of medical eligibility. SSA reimburses the states for the full costs of the DDSs.The DDSs apply a sequential decision process specified by SSA to make an initial decision whether a claim should be allowed or denied. If the claim is denied, the decision can be appealed through several levels of administrative and judicial review. On average, the DDSs allow 37 percent of the claims they adjudicate through the five-step process. A third of those denied decide to appeal, and three-quarters of the appeals result in allowances. Nearly 30 percent of the allowances made each year are made during the appeals process after an initial denial.In 2003, the Commissioner of Social Security announced her intent to develop a "new approach" to disability determination. In late 2004, SSA asked the Institute of Medicine (IOM) to help in two areas related to its initiatives to improve the disability decision process: 1) Improvements in the criteria for determining the severity of impairments, and 2) Improvements in the use of medical expertise in the disability decision process.This interim report provides preliminary recommendations addressing the three tasks that relate to medical expertise issues, with a special focus on the appropriate qualifications of medical and psychological experts involved in disability decision making. After further information gathering and analyses of the effectiveness of the disability decision process in identifying those who qualify for benefits and those who do not, the committee may refine its recommendations concerning medical and psychological expertise in the final report. The final report will address a number of issues with potential implications for the qualifications of the medical experts involved in the disability decision process.

More than 5,800 military personnel, mostly Navy personnel and Marines, participated in a series of tests of U.S. warship vulnerability to biological and chemical warfare agents, Project SHAD (Shipboard Hazard and Defense), in the period 1962-1973. Only some of the involved military personnel were aware of these tests at the time. Many of these tests used simulants, substances with the physical properties of a chemical or biological warfare agent, thought at the time to have been harmless. The existence of these tests did not come to light until many decades later.

In September 2002, the Institute of Medicine (IOM) agreed to undertake a scientific study, funded by the Veterans'' Affairs, of potential long-term health effects of participation in Project SHAD. In general, there was no difference in all-cause mortality between Project SHAD participants and nonparticipant controls, although participants statistically had a significantly higher risk of death due to heart disease, had higher levels of neurodegenerative medical conditions and higher rates of symptoms with no medical basis.

Long-Term Health Effects of Participation in Project SHAD focuses on the potential health effects of participation in Project SHAD. It is a useful resource for government defense agencies, scientists and health professionals.

The Social Security Administration (SSA) provides Social Security Disability Insurance (SSDI) benefits to disabled persons of less than full retirement age and to their dependents. SSA also provides Supplemental Security Income (SSI) payments to disabled persons who are under age 65. For both programs, disability is defined as a "medically determinable physical or mental impairment" that prevents an individual from engaging in any substantial gainful activity and is expected to last at least 12 months or result in death.Assuming that an applicant meets the nonmedical requirements for eligibility (e.g., quarters of covered employment for SSDI; income and asset limits for SSI), the file is sent to the Disability Determination Services (DDS) agency operated by the state in which he or she lives for a determination of medical eligibility. SSA reimburses the states for the full costs of the DDSs.The DDSs apply a sequential decision process specified by SSA to make an initial decision whether a claim should be allowed or denied. If the claim is denied, the decision can be appealed through several levels of administrative and judicial review. On average, the DDSs allow 37 percent of the claims they adjudicate through the five-step process. A third of those denied decide to appeal, and three-quarters of the appeals result in allowances. Nearly 30 percent of the allowances made each year are made during the appeals process after an initial denial.In 2003, the Commissioner of Social Security announced her intent to develop a "new approach" to disability determination. In late 2004, SSA asked the Institute of Medicine (IOM) to help in two areas related to its initiatives to improve the disability decision process: 1) Improvements in the criteria for determining the severity of impairments, and 2) Improvements in the use of medical expertise in the disability decision process.This interim report provides preliminary recommendations addressing the three tasks that relate to medical expertise issues, with a special focus on the appropriate qualifications of medical and psychological experts involved in disability decision making. After further information gathering and analyses of the effectiveness of the disability decision process in identifying those who qualify for benefits and those who do not, the committee may refine its recommendations concerning medical and psychological expertise in the final report. The final report will address a number of issues with potential implications for the qualifications of the medical experts involved in the disability decision process.