The use of epidemiological evidence in the compensation of veterans

Men and women serving in the U.S. military are exposed to diverse agents that may affect their health, causing injury and disease while they are in the service or after discharge. This case study addresses the compensation of veterans for injury and illnesses arising from exposures received during military service and focuses on the presumptions that are made around compensation of veterans for conditions arising after their service. Presumptions are made because of evidence gaps related to exposure and causation. The current process for evidence review related to causation involves Institute of Medicine (IOM) committees that evaluate evidence relevant to association. The Veterans Administration uses the IOM reports in making presumptions. A new approach was recommended by an IOM committee: a transparent, evidence-based approach that would lead to decisions by means of an explicit process. The Committee set out six principles as a foundation for its framework: stakeholder inclusiveness, evidence-based decisions, transparent process, flexibility, consistency, and the use of causation, not just association, as the basis for decision making. The committee also called for needed tracking of exposure and associated health outcomes during and after military service. This case study covers "lessons learned" around evidence synthesis, causal inferences, and decision-making.