Barriers and Facilitators to Administering Burn Pit Registry Exams in VHA Facilities

ABSTRACT

Introduction

The Veterans Health Administration (VHA) established the Airborne Hazards and Open Burn Pit Registry (AHOBPR) in 2014 to address exposure concerns for veterans who have served in military operations in Southwest Asia and Afghanistan. By 2021, over 236,086 veterans completed the online questionnaire and 60% requested an AHOBPR examination. Of those requesting an exam, only 12% had an exam recorded in their medical record. This article summarizes barriers and facilitators to delivering AHOBPR exams and shares lessons learned from facilities who have successfully implemented burn pit exams for veterans.

Materials and Methods

We (I.C.C and J.H.) constructed a key performance measure of AHOBPR examination (the ratio of examinations performed in facility over examinations assigned to a facility) to identify top performing facilities and then used stratified purposeful sampling among high-performing sites to recruit a diverse set of facilities for participation. We (P.V.C. and A.A.) recruited and interviewed key personnel at these facilities about their process of administering burn pit exams. Rapid qualitative methods were used to analyze interviews.

Results

The ratio of exams performed to exams assigned ranged from 0.00 to 14.50 for the 129 facilities with available information. Twelve interviews were conducted with a total of 19 participants from 10 different facilities. We identified 3 barriers: Unclear responsibility, limited incentives and competing duties for personnel involved, and constrained resources. Facilitators included the presence of an internal facilitator, additional staff support, and coordination across a facility’s departments to provide care.

Conclusions

Gaps across many VHA facilities to provide AHOBPR exams may be understood as stemming from organizational issues related to clear delegation of responsibility and staffing issues. VHA facilities that wish to increase AHOBPR exams for veterans may need additional administrative and medical staff.

INTRODUCTION

From 1990 to 2015, more than 3.7 million U.S. service members deployed to military operations in Southwest Asia and Afghanistan. Because alternative waste management systems were unavailable at military bases in these regions, all waste material—from plastics to fecal matter—were disposed of in large open burn pits next to military camps, exposing service members to toxic fumes and particulate matter.^1,2 When service members returned home, many sought care for a variety of symptoms (e.g., shortness of breath and reduced exercise capacity) and illnesses (e.g., asthma and cancers) thought to be related to burn pit smoke, ambient air pollution, dust storms, and other airborne hazards encountered during deployment. Ongoing research shows that those deployed to Southwest Asia and Afghanistan regions have higher prevalence of certain symptoms and certain respiratory conditions compared to those who were not deployed to these regions.^3–7

In 2014, the Veterans Health Administration (VHA) established the Airborne Hazards and Open Burn Pit Registry (AHOBPR) in response to Public Law 112-260.⁸ The AHOBPR is an online questionnaire where veterans can submit information on their demographics, self-reported exposures, conditions, and other relevant information. Veterans can also indicate interest in a clinical examination to address exposure concerns through the registry. Although Public Law 112-260 specified which veterans and service members were eligible to participate in the registry and detailed many of the research benefits of the registry, little was said on who should be performing exams—only that veterans could contact their patient aligned care team (within primary care) or the VHA environmental health coordinator in their area.

In 2016, VHA released information to guide facilities in delivering exams for veterans with exposure concerns, including training webinars and a downloadable exam toolbox. These were intended for physicians, physician assistants (PAs), and nurse practitioners who would be seeing veterans.^9,10 Which department these providers would belong to—environmental health, primary care, and compensation and pension—did not appear to be specified.

In 2019, VHA issued a directive mandating delivery of AHOBPR exams and made concerted efforts to educate VHA providers on the importance of the AHOBPR and how to conduct an exam.¹¹ This directive stated that facilities should designate a lead environmental health clinician to conduct exams. At the same time, the environmental health clinician would work closely with primary care providers, advising them on all aspects of the AHOBPR exam and sending veterans back to their primary care providers for any future treatment.

By March 2021, more than 236,086 veterans had completed the AHOBPR online questionnaire. A majority, 60% (142,298), requested an exam. Of those who requested an exam, only 12% (17,408) had received one.

This article explores barriers and facilitators to delivering AHOBPR exams to veterans. We highlight findings and implications that are potentially applicable more generally to health care systems that must consider how to establish and sustain novel clinical services, especially those outside of usual care processes, contributing to the broader conversation on how institutional and organizational factors enable or impede new evaluation and treatment services. Also, we offer concrete lessons learned for VHA researchers and facilities on the operational factors that impact the administration of new clinical service offerings for veterans.

The article is based upon work supported by the VHA’s Airborne Hazards and Open Burn Pit Center of Excellence, as well as the Center for Innovations in Quality, Effectiveness, and Safety, a VHA Health Services Research & Development Service funded organization.

METHODS

Overview

Although the lack of registry exams was a widespread problem throughout the VHA, our goal was to understand the operational practices of sites actively engaged in providing AHOBPR exams to veterans. Our project design explores positive deviance: We used information from sites that were able to successfully administer burn pit examinations for veterans. The project team decided to only interview high-performance facilities, rather than facilities across a range of performance levels, to increase the likelihood of participation and because our interest lay in understanding the practices of sites successfully engaged in providing AHOBPR exams to veterans. But even while we spoke to those who were more successful in administering AHOBPR exams, we were able to learn of the many challenges they faced, and many spoke to broader issues effecting facilities within the VHA health care system.

Our methods for sampling and data collection bring together quantitative and qualitative techniques.¹² We used quantitative methods to construct a performance measure and stratified purposeful sampling to identify high-performing sites.¹³ We used qualitative methods to learn these sites’ processes for performing AHOBPR exams, conducted interviews, and analyzed data through rapid analysis.

Constructing a Performance Measure

The population for this project included 129 out of the 140 (92%) VHA parent facilities (11 were excluded because of missing data). It should be noted that we use the terms “facility” and “site” interchangeably in this project. A facility or site refers to the parent VHA medical center or health system, which include community-based outpatient clinics. The authors used Microsoft SQL Server Management Studio 18.9.1 and R version 4.0.5 for data extraction from a national database of AHOBPR data and VHA Corporate Data Warehouse (CDW), a nationwide electronic medical record database.¹⁴

A performance measure was constructed using 2 variables: (1) The number of veterans assigned to a facility who requested an exam (“Assigned”); and (2) the number of AHOBPR exams performed at a facility (“Exams Performed”).

The “Assigned” variable is drawn from the national AHOBPR data system. Veterans who had indicated a desire for a registry exam on their questionnaire would, through this data system, be assigned to a facility where they could have an exam completed. Assignments were based on veteran location or where they were enrolled. A VHA facility would need to access the AHOBPR data system in order to obtain the list of veterans assigned to them.

The “Exams Performed” variable is drawn from CDW database. It captures whether a facility was providing exams for veterans and how many it conducted within the study period (see later). Occurrence of an examination was detected by the presence of a signed “AHOBPR Initial Evaluation” clinician note title in VHA electronic medical record in CDW. The ratio of exams performed over the number assigned, hereafter referred to as E/A ratio, constituted our key performance measure. Facilities were ordered from high to low E/A ratio.

We limited our facility metrics to the time period of October 1, 2018, through March 31, 2021. This time period includes the beginning of the Coronavirus Disease 2019 (COVID-19) pandemic, which significantly affected clinical care across many health systems, including VHA. This influenced which facilities were able to continue offering AHOBPR exams and rank with higher E/A ratios. Although it is beyond the scope of this article to consider how the COVID-19 pandemic may have influenced delivery of AHOBPR exams, we acknowledge that many of the sites that were able to continue or even improve delivery of AHOBPR exams during the COVID-19 pandemic may have enjoyed unique circumstances that allowed them to do so.

Stratification of Facilities

After constructing the E/A ratio, facilities were ordered from high to low according to their E/A ratio. The top 30 (roughly the top quartile) facilities in this simple ordering all had higher complexity scores and larger numbers of enrolled patients. Although there were some small facilities with high E/A ratios, none were represented in the initial top 30, because smaller facilities tended to have lower volumes of veterans assigned to them.

To address this, we stratified facilities by volume—the number of veterans assigned on average per quarter to a facility for an AHOBPR exam. Facilities were grouped into high-volume (more than 10 veterans assigned per quarter), high-performing facilities, and low-volume (10 or fewer assigned per quarter), high-performing facilities. To ensure that lower volume, smaller facilities would be included among sites we interviewed, we selected sites from both strata for recruitment.

Additional Selection Criteria

The project team also considered the following criteria during the selection process to ensure a diverse set of facilities would be represented: Facility complexity, proximity to a military base, and geographical region.

Facility complexity is based on VHA’s classification that incorporates patient population, clinical services, administrative complexity, and research and education to construct a facility complexity index.^15,16 VHA’s complexity model identifies 5 levels (1a, 1b, 1c, 2, and 3) of complexity, with level 1a being the most complex and level 3 being the least complex. To the extent possible, we sought representation across all complexity levels among sites recruited for interview.

Historically, several facilities near military bases partnered with base leadership to inform separating service members (i.e., new veterans) about the AHOBPR registry and exams. We selected facilities both close to (Proximate: Yes) and far from (Proximate: No) military bases. Proximity was determined via a matrix calculation using geographic coordinates of military bases and VHA facilities. Facilities within 100 kilometers of a military base were considered proximate.

Finally, we sought to diversify sites by geographic region, selecting sites across Northeast, Southern, Midwestern, and Western regions.¹⁷

Interview Recruitment

We selected a total of 10 sites for priority recruitment, with an additional 3 sites as “backup” pending refusal or non-response from priority sites. For each site, we found the site’s environmental health coordinator through publicly available VHA directories. We used CDW records to find the provider(s) at each site who had conducted the greatest number of AHOBPR exams. Coordinators and providers were emailed to request interviews.

Data Collection

We developed an interview guide in collaboration with clinical experts of the AHOBPR exams. Questions centered on 3 primary areas of interest: The facility’s process for learning about evaluation requests and conducting exams, strengths or advantages of the process, and recommended improvements (see Appendix for Interview Guide). The interviews were largely open-ended, beginning with a “grand tour” question (“Typically, how does your facility go from learning about a patient who has requested an exam to conducting an exam for them?”).¹⁸ As a more “participant-led’ interview, clarifying questions and additional probes were guided by the conversational flow.

Some of our interviewees invited their colleagues to participate in a group interview. While including the occasional group interview departs from typical qualitative design procedures that use individual interviews and focus groups for different analytic purposes, because the goal of our project was to explore site-level operations and practices, we felt both one-on-one and group interviews could be informative. Additionally, we wished to respect participants’ desires to include colleagues and the tacit implication that this would benefit both our inquiry and their own professional relationships.

Interviews were conducted through a teleconferencing platform (MS Teams) from June to September 2021 and lasted 30 minutes to 1 hour. All interviewees gave permission to record. VHA Centralized Transcription Service transcribed audio files. As an operational, quality improvement project, the project was designated as quality improvement by the VHA’s Office of Patient Care Services, Health Outcomes Military Exposures.

Qualitative Data Analysis

Rapid analysis informed our analytic protocols.¹⁹ Interview notes were collected during the interview by a project team member. Interviewers created summaries using notes and cross-checking with audio-recording, as needed. To create summaries, a template was used with the domains that were informed by the interview guide (see Appendix for Template). Summaries worked to standardize content for analysis. After all interviews were completed, a matrix was created to facilitate comparison across sites.²⁰ Transcripts were used to add missing detail and to draw supporting quotations.

RESULTS

The E/A ratio ranged from 0.00 to 14.50 for the 129 facilities in our population of facilities. We stratified high-performing sites into high- and low-volume groups. There were 10 high-volume sites and 20 low-volume sites within the sample. For the high-volume group, E/A ratios ranged from 2.4 to 11.3, with mean = 4.9 and SD = 2.7. For the low-volume group, E/A ratios ranged from 1.8 to 14.5, with mean = 4.4 and SD = 3.1.

The presence of facilities with E/A ratios greater than 1 indicates that some facilities conducted exams for veterans beyond the number of those assigned to them through the AHOBPR system. This would have occurred if a veteran received an exam without requesting one through the “official” AHOBPR questionnaire. While it is true that official VHA guidance dictated that all veterans must complete the questionnaire before receiving an exam and indicate their interest in an exam through the questionnaire,²¹ in practice, this simply was not the case. Providers may have simply conducted an AHOBPR evaluation if a veteran requested one by calling or asking staff at a facility directly. As well, some facilities would call and check on veterans who did not indicate interest in an exam on the questionnaire, and veterans would then agree to receive an exam through direct outreach from the facility. In both these circumstances, while there would be no assignment record in the AHOBPR database (A), a VHA facility’s electronic medical records would show the presence of an AHOBPR Initial Evaluation note (E) once an exam was completed. There were also instances in which a veteran relocated after completing the questionnaire and then received an exam at a facility in their new location. Under these circumstances, the veteran’s previous facility would still have an unfulfilled assignment on record, while the facility in the veteran’s new location would receive the “credit” for their exam.

Of the 10 original sites selected for interviews, 8 sites accepted invitations for participation. One site did not respond, and one site declined because of recent personnel changes that impacted their AHOBPR activities. These 2 sites were replaced with 2 “backup” sites from the same volume strata. Table I provides an overview of the facility characteristics of sites we interviewed.

We conducted 12 interviews with a total of 19 participants from 10 different sites.

Among the 10 sites interviewed for this project, 4 were high volume, and 6 sites were low volume. Eight were high-complexity facilities, 1 was medium complexity, and 1 was low complexity. Five sites were in close proximity to military bases, and 5 sites were not close to military bases. Five sites were located in the South, 2 in the Midwest, 2 in the West, and 1 in the Northeast region. It is worth noting that the geographic distribution of our selected facilities is not representative of the actual distribution of VHA facilities across the country, where Northeast facilities outnumber southern facilities.

The specific professional role of the interview participant(s) varied across sites and reflected who was willing to participate at the site. Table II shows information on interview participants at each site and whether interviews were one-on-one or team-based.

Understanding the AHOBPR Process

Using interview data, our team constructed a process map illustrating the administrative and clinical steps required to provide AHOBPR exams. Fig. 1 presents the process map.

What is most notable are the steps or actions using separate AHOBPR mechanisms. There are multiple instances in which facility staff are collecting information from or inputting information into specialized AHOBPR data records. This highlights how the process of getting a veteran seen for their AHOBPR exams was bifurcated from all other facility administrative processes. The AHOBPR questionnaire data existed in an online platform (Veterans Integrated Registry Platform) outside of the integrated VHA electronic health records and consult system. Additional AHOBPR tasks often included keeping separate records of AHOBPR veterans and whether an exam was performed for them. The bifurcation of AHOBPR exams from facility systems shapes both the barriers to and facilitators for delivering exams.

Barriers to Delivering Exams

Although the sites we interviewed were high performers, many interviewees provided (unprompted) information as to why so many facilities struggle to conduct AHOBPR exams. We identified 3 barriers facilities face in conducting exams: Unclear responsibility, limited incentive, and constrained resources.

Unclear responsibility

AHOBPR exams touch on issues of relevance to multiple clinical services, including primary care, pulmonary specialty care, post-deployment health, occupational and environmental medicine, and compensation and pension. Although VHA 2019 mandate directed facilities to appoint an environmental health clinician to take lead on exams, the staff we spoke to indicated that, in practice, there was a lack of clarity within facilities around which department should be responsible for conducting exams and how to reallocate limited time and resources. A clinician from one site stated:

I see a lot of those exams kicked to us, rather than having their medical folks take care of it themselves, so the post-deployment health sometimes gets kicked to me, rather than to primary care. (Site C, Physician Assistant)

The experience illustrates the lack of agreement about organizational ownership of the AHOBPR exam service. While the physician assistant quoted here was willing to take on the task of providing the exam for veterans, unclear responsibility in terms of which department should be responsible for conducting exams could have impacted other facilities’ ability to appropriate place and administer the service.

Limited incentive to conduct exams

Facility reluctance to conduct exams may also be because AHOBPR exams are perceived as outside of usual clinical services. Exams are conducted separately from standard clinical care. At the time of our data collection, they were neither included in facility performance metrics nor considered “countable” work load credit for co-pays or third-party insurance reimbursement. One respondent referred to exams as a “collateral duty” (Site C, Physician Assistant), and another understood that exams were considered “ancillary” (Site I, Nurse Practitioner) by facility leadership. As one of our respondents explained:

Registry exams, because they are administrative exams, I think the impression from leadership is that these are lost… capital funding exams, where it’s money out the door. ...My impression [is] that they would say to themselves, ‘Why should …we try to do more Registry exams? When all we’re doing is… tying up providers’ time, and we’re not really creating any more money for the facility.’ (Site D, Clinic Director)

The respondent’s assessment that facility leadership would view AHOBPR exams unfavorably because they do not “make any more money” may appear contradictory, given VHA is a federally funded, not-for profit health system. However, at the time of interview, some VHA facilities categorized AHOBPR exams as a “no count” service—not countable toward the facility workload metrics which are tied to larger funding allocations for a facility. The additional administrative and clinical burden of conducting AHOBPR exams, in combination with the diversion of time and personnel away from “countable” services, may have created a disincentivizing set of circumstances for conducting exams.

Constrained resources

The perception of the AHOBPR exam as an administrative service of limited value may diminish the imperative for facility leadership to prioritize resource allocation to these exams. Many facilities may be hard-pressed to allocate the necessary financial resources required to conduct exams:

…If you really want a program to be ran with any degree of urgency, you can’t just … expect it to happen magically … You’re always going to compete with other priorities at the VISN and facility-level. And end up losing more often than not. (Site J, Administrative Officer)

Despite the many challenges facilities face in providing exams, interviewees shared how they were nevertheless able to overcome these challenges.

Facilitators for Delivery of AHOBPR Exams

Interviews with high-performing sites revealed variation in their operational practices. Table III shows different administrative and clinical activities of facilities.

Because our interviews were open-ended and allowed interviewees to drive much of the discussion, not all sites spoke on all activities featured in the table. We present this table as an organizational heuristic. Although no single activity or practice was found across all sites to explain their success, we identified 3 common features: An internal facilitator, additional administrative and clinical support, and intra-facility coordination.

Internal facilitators

The presence of an “internal facilitator”²² or champion—a highly motivated staff member driving the AHOBPR program—was key. In some facilities, clinical personnel stood out as the site’s AHOBPR champion, taking on the bulk of the exam responsibilities. At other sites, the environmental health coordinator or a medical support assistant was recognized as a key administrative force driving facility success.

We asked our interviewees what they thought were important characteristics for a champion leading AHOBPR efforts. Perhaps unsurprisingly, when interviewing clinicians, the importance of strong medical expertise was emphasized as a factor instrumental to program success and exam completion. One provider felt that:

It’s better to have a medical doctor provider. …because they can go to the depth of the problem. They can give the differential diagnosis…, one of the recommendations is that a medical doctor is important to be treating and diagnosing the cases, because they are actually working in this field, and they have been trained in that. (Site B, Physician)

It is worth noting that we interviewed many dedicated nurse practitioners and physician assistants who were well versed in the clinical protocol for the exam. We present the above quote to highlight variation among our respondents and the lack of consensus around the most important characteristics of an AHOBPR champion. While the physician from site B emphasized the importance of being able to make differential diagnosis, other sites highlighted the importance of administrative personnel, especially those who are veterans.

It’s really in your administrative staff so that you have people who know what they’re doing. And, you know, I had questions that I didn’t know about… and I’d go ask [Environmental Health Coordinator] and he would know the answer—‘Cause he was a veteran himself… He could tell people where to go for help and connected to the different services both inside the VA and outside of the VA, for people who had those particular problems… He was the one who knew more of the nuts and bolts. (Site D, Clinic Director)

Rather than their professional status as clinical or administrative personnel, the more salient feature of the AHOBPR internal facilitator was their ability to work across administrative and clinical lines and across VHA health system, military bases, and veteran community organizations.

Additional administrative and clinical support

Because requests for AHOBPR exams exist outside of VHA electronic record and consult system, processing requests required a significant amount of personnel effort. Particularly in the early stages of conducting AHOBPR exams, individual sites described having an accumulation of hundreds—even thousands—of pending exam requests. A clinical administrator at one site detailed the administrative work involved for sites just beginning to address these requests:

I’ve reorganized that into pending lists by calendar year and then tried to streamline from a scheduling practice… I’m going back right now to clean up our backlog. (Site E, Environmental Health Coordinator)

Additional clinical support also facilitated getting veterans seen for the AHOBPR exam. A few sites were able to bring in providers paid per exam (“fee basis providers”) to help them process the large numbers of exams:

Because we said … we’re gonna have 200 exams all of a sudden and doing 20 a week it’s gonna take us 10 weeks to catch up … you can bring in a fee basis person and it’s not too hard, I don’t think, to train somebody to do the Registry exams. (Site D, Director)

Strong administrative personnel who can streamline scheduling and other administrative processes and additional clinical personnel may be necessary to address high volumes of pending requests.

Coordination across facility departments

High-performing sites recommended conscientiously coordinating with primary care, pulmonary, and diagnostic departments to ensure complete care for veterans.

Because we need some tests that are done in our facility, like [Pulmonary Function Tests], for example, we maintain close communication and collaboration with … [the] pulmonary function test clinic… So we try to make sure that we understand the challenges that this [pulmonary] clinic has, and our needs, and we try to balance that to make sure both needs are met. (Site J, Chief of Compensation and Pension)

Coordinating across departments enabled facilities to deliver higher quality care for their patients.

DISCUSSION

While the AHOBPR exam is a highly visible service at the core of VHA mission “to care for those who have borne the battle,” many facilities struggled with delivering these exams from 2014 to 2020. The information for scheduling and tracking AHOBPR veterans existed outside VHA facilities’ systems for usual health information access and documentation, creating an additional administrative burden for clinicians and coordinators. Related barriers such as limited resources to cover the additional administrative and clinical need, ambiguous and variable designation of which departments should be delivering exams, and the sense that exams were an “ancillary service,” all worked in concert to further challenge delivery of these exposure exams.

In summer 2022, U.S. lawmakers passed the “Promise to Address Comprehensive Toxics Act” expanding benefits for eligible, deployed veterans with conditions deemed likely related to their military exposures.²³ While the new legal mandates enhance access to care and disability benefits, understanding the organizational dynamics of the health facilities charged with providing this evaluation is essential to ensuring accessible, efficient, high-quality delivery of care.

A 2022 report by Office of Inspector General on the AHOBPR exam process recommended administrative improvements and the development of metrics to measure facility performance.²⁴ Our findings have resulted in specific recommendations for facilities attempting to implement registry exams. First, we suggest designation of a supported internal facilitator who can engage in coordinating the administrative and clinical activities related to providing AHOBPR exams. Second, facilities should maintain open channels of communication across departments and services and work together to ensure that the complex needs of veterans with exposure concerns are addressed. Creating integrated clinics may further enable these registry exams to bring more veterans into care.²⁵ Third, facilities should calculate the need and allocate adequate resources to reassign or hire and train administrative and clinical personnel to complete the work of the AHOBPR exams. Failure to address military exposure concerns has had serious and long-lasting negative impacts on other cohorts of veterans and could be avoided.²⁶

The lessons learned here are applicable to other health care systems. As new evidence-based screening and surveillance interventions, such as low-dose CT of the chest for lung cancer screening, enter the standard of care, systems and facilities must find ways to serve the population of patients under their care.²⁷ There is a strategic consideration for an organization when deciding whether to offer a new service or not and many factors, including cost, revenue potential, volume, public relations/goodwill, and collateral benefits, contribute to the decision. Our findings reflect the perceptions of individuals close to the “front line” of delivering the AHOBPR exam, most of whom were not key decision makers at their local facilities, but many of whom were aware of the national VHA requirement to perform this service.

Limitations

It is possible that there were some providers who performed an AHOBPR exam for a veteran but did not document that exam through a note title and that our figures undercount the number of exams performed during the time period analyzed. However, it was not practically feasible to estimate the total number of undocumented AHOBPR exams within the time period, as this would have required a facility-by-facility survey of what other note titles, if any, providers at a given facility may be using, which was outside the scope of our project activities.

Also, given the diversity and the small number of facilities we spoke to, attempting to make causal inferences between existing practices and performance measures through statistical analysis was not appropriate. The primary purpose of our qualitative data collection was to inform contemporaneous quality improvement and implementation activities to increase the number of AHOBPR exams performed as well as the veteran and provider satisfaction with the encounters. We share with other organizations the empirically supported strategies in this document as examples they might find relevant.

CONCLUSION

Implementing a novel health care service, like the AHOBPR exam, can present challenges, including unclear responsibility, misaligned incentives, and inadequate resources. Identifying and addressing these barriers and ensuring the presence of a potent champion and coordination among stakeholders can promote success. Lessons learned from this project on AHOBPR exam implementation in VHA may be informative to other settings and service implementation.

ACKNOWLEDGMENTS

We thank Immanuelle I. Azebe-Osime for her contributions to data collection and Drs Aaron Schneiderman and Eric Shuping for their editorial insights and improvements.

SUPPLEMENTARY MATERIAL

SUPPLEMENTARY MATERIAL is available at Military Medicine online.

FUNDING

The material is based upon work supported by the VHA’s Airborne.

Hazards and Open Burn Pit Center of Excellence.

CONFLICT OF INTEREST STATEMENT

None declared.

DATA AVAILABILITY

Data and materials in this article can be made available to individuals upon reasonable request by contacting Patricia Chen ([email protected]).

CLINICAL TRIAL REGISTRATION

Not applicable.

INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)

We conducted an operational, quality improvement project. The project was determined not to require review by an institutional review board because it was not human subjects research and was designated as quality improvement by VHA’s Office of Patient Care Services, Health Outcomes Military Exposures. The need for study approval and informed consent was waived by the VHA’s Office of Patient Care Services, Health Outcomes Military Exposures. All methods were carried out in accordance with the relevant guidelines and regulations. We did not obtain verbal informed consent as the project was not human subjects research. The project was an operations project to improve care delivery. Out of respect for the individuals, we asked all interviewees if they gave permission to participate in and record the interview and all agreed. This project did not involve experiments on human subjects.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)

Not applicable.

INDIVIDUAL AUTHOR CONTRIBUTIONS STATEMENT

P.V.C. led the conducting of interviews and contributed to formal analysis and writing of original draft as well as reviewing and editing. I.C.C. contributed to statistical analysis and writing of statistical sections of original draft as well as reviewing and editing. K.M.G. contributed to writing, reviewing, and editing. J.H. contributed to statistical analysis. N.J. and A.S. contributed to conceptualization. A.A. contributed assisted in interviewing and prepared Figure 1. D.A.H. contributed to supervision, writing, and editing.

All authors reviewed the manuscript.

INSTITUTIONAL CLEARANCE

Institutional clearance does not apply.

REFERENCES

Author notes